COLUMBIA  LIBRARIES  Ul-f&nc 

HEALTH  SC1ENCES_STANDARD 


Hyn0041904 


RECAP 


Columbia  ^ntbersitp        \ 
in  ttje  Citj)  of  i^eto  gorfe 

College  of  ^lipgiciang  anti  ^urgeonsf 


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in  2010  with  funding  from 

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http://www.archive.org/details/publichygiene01blai 


A  PARK  LAKE,  FORMERLY  A  MALARIAL  SWAMP  OF  NO  VALUE 

THE  SHALLOW  LAKE  SHOWN  IS  CHOKED  WITH  WEEDS  AND  IS  INSANITARY 

A  PROPERLY  CONSTRUCTED   ARTIFICIAL  LAKE  STOCKED  WITH    FISH  AND  FOWL 


PUBLIC  HYGIENE 


BY 


THOS.  S.  BLAIR,  M.D. 

Neurologist   Harrisburgh,   Pennsylvania,   Hospital,   Author    "A   Practitioner's 

Handbook  of  Materia   Medica,"    "A    Practitioner's    Handbook 

of  Modern  Medical    Treatment,"    etc. 


ASSISTED  BY  NUMEROUS  CONTRIBUTORS 


IN  TWO   VOLUMES.      VOLUME  I 

With  158  illustrations 


RICHARD  G.  BADGER 

BOSTON 


Copyright  1911  by  RICHARD  G.  BADGER 
Entered  at  Stationers'  Hall 


All  rights  reserved 


THE  GORHAM  PRESS,  Boston,  U.  S.  A. 


THIS   BOOK    IS    DEDICATED 

TO  THE  MEMORY  OF 
THE    NOBLE    PHYSICIANS    AND   MARTYRS 

WHO    LAID    DOWN    THEIR    LIVES 

IN    THE    CAUSE    OF    SANITATION 

THAT  THE  MANY  WHO  PROFIT  BY  THEIR  DISCOVERIES 

MIGHT  LIVE 


PREFACE 

The  proceedings  of  the  annual  conferences  of  state  and  territorial  health 
officers  with  the  United  States  Public  Health  and  Marine-Hospital  Service 
have  developed  so  many  points  of  friendly  difference  regarding  various 
sanitary  procedures  that  the  present  author  has  been  led  to  institute  a  per- 
sonal investigation  of  public  hygiene  from  the  standpoint  of  a  seasoned  gen- 
eral practitioner  of  medicine  and  w^hich  investigation  embraces  a  wide  area 
of  this  country. 

The  decision  has  been  reached  that  public  hygiene  has  developed  too  much 
as  a  specialty  and  needs  the  tempering  conclusions  of  the  whole  body  of  the 
medical  profession.  Such  conclusions  must  result  from  a  careful  comparison 
of  laboratory  and  clinical  data  and  no  one  class  of  men  are  so  fully  qualified 
to  weigh  them  as  is  the  class  to  whom  this  volume  is  especially  addressed. 

But  in  order  to  do  so  the  family  doctor  must  inform  himself  not  only  upon 
the  pathological  and  clinical  aspects  of  the  work,  but  also  upon  the  socio- 
logic,  legal,  and  engineering  factors  involved.  The  effort  is  here  made  to 
present  reliable  data  upon  the  present  very  creditable  development  of  this 
important  subject,  and  in  doing  so  the  author  poses  more  as  an  editor  than  as 
an  original  writer  and  has  endeavored  to  judicially  weigh  the  evidence  at 
hand  upon  a  basis  of  real  accomplishment  rather  than  upon  that  of  a  propa- 
ganda. Where  especial  information  is  needed  that  is  foreign  to  the  work  of 
the  clinician,  the  special  worker  and  the  various  organizations  identified 
with  health  administration  have  very  courteously  supplied  the  deficiencies.  A 
listof  contributors  will  be  found  following  this  explanatory  foreword.  To 
them  and  to  a  large  number  of  others  interviewed,  the  author  acknowl- 
edges  a  great  debt  of  obligation. 

Largely  fathered  by  the  Harrisburg  Academy  of  Medicine,  the  extensive 
library  of  that  institution  and  several  of  its  Fellows  have  aided  me  in  the 
preparation  of  this  book. 

A  great  work  in  preventive  medicine  faces  the  rank  and  file  of  the  phy- 
sicians, a  work  singularly  appealing  to  the  representative  people  in  many  walks 
of  life.  Never  before  have  the  great  American  public  so  fully  joined  hands 
with  the  doctor.  In  deference  to  them  and  in  recognition  of  their  creditable 
and  proper  concern,  this  medical  book  aims  to  present  what  the  intelligent 
laymen  are  doing  and  offers  for  their  study  much  that  is  of  joint  interest  to 
them  and  to  the  physicians.  The  work  in  public  hygiene  cannot  be  effectively 
done  without  the  inteUigent  and  enthusiastic  efforts  of  my  colleagues;  neither 
can  we  do  it  all.  The  trio  involved  consists  of  the  public  health  adminis- 
tration, the  medical  profession,  and  the  great  American  public. 


vi  HYGIENE 

Doubtless  the  author  has  made  some  mistakes  herein,  but  the  hope  is 
expressed  that  they  be  viewed  kindly  since,  so  far  as  ascertained,  this  is  the 
first  eflFort  to  present  a  work  from  this  especial  point  of  view  in  the  great 
domain  of  public  health.  The  illustrations  were  largely  made  or  collected  by 
the  author  during  trips  of  inspection.  The  largely  academic  and  the  merely 
literary  have  been  merged  in  the  definite  seen  or  heard  upon  the  spot  or  de- 
rived from  original  sources,  and  the  work  must  be  judged  accordingly.  It  is 
the  very  earnest  hope  of  the  writer  that  the  splendid  class  of  men  with  whom 
professional  affiliations  identify  me  may  study  this  and  other  works  upon  our 
public  obligations  and  join  forces  with  the  earnest  sanitarians  of  the  boards  of 
health,  for,  let  me  assure  you,  they  need  us. 

June  1,  1910.  T.  S.  B. 


CONTRIBUTORS  TO  THE  WORK 

David  S.  Funk,  A.B.,  M.D. 

Physician,  Interne  Department,  Harrtsburg  Hospital. 
W.  E.  Wright,  M.D. 

Formerly  Resident  Physician,  Bay  View  Asylum,  Baltimore;  Resident 
Clinical  Royal  Asylum,  Edinburgh;   Late  First  Assistant,  Pennsylvania 
State  Hospital;  Neurologist,  Harrisburg  City  Hospital. 
W.  Blair  Stewart,  A.M.,  M.D. 

Formerly    Instructor    in    Medico    Chirurgical    College,    Philadelphia; 
Member  Visiting  Staff,  Atlantic  City  Hospital,  etc. 
Charles  S.  Rebuck,  M.D. 

Medical  Inspector,   Public   Schools;    Assistant   Surgeon,   Ear,  Nose, 
and  Throat  Department,  Harrisburg  Hospital. 
John  Uri  Lloyd,  Phar.  M.,  Cincinnati,  Ohio. 
J.  B.  McAlister,  A.m.,  M.D. 

Chairman,    Committee    on    Legislation,   Pennsylvania    State   Medical 
Society;   Physician  Interne  Department,  Harrisburg  Hospital. 
J.  Horace  McFarland 

President,  American  Civic  Association. 
J.  Wesley  Ellenberger,  M.D. 

Assistant  Chief  Physician,  Pennsylvania  Department  of  Health  Tuber- 
culosis  Dispensary  Work. 
J.  J.  Taylor,  M.D. 

Editor,  Medical  Council,  Philadelphia. 
Harvey  F.  Smith,  Ph.B.,  M.D. 

Dispensary  Surgeon,  Harrisburg  Hospital 
H.  C.  FoLGER,  Jr. 

Standard  Oil  Company,  New  York  City. 
Clarence  R.  Phillips,  M.D. 

Pathologist;   Assistant  Physician  Pennsylvania  Department  of  Health 
Tuberculosis  Dispensary,  No.  13. 
William  G.  Snow 

Heating  and  Ventilating  Engineer  (Boston);  Past  President,  American 
Society  of  Heating  and  Ventilating  Engineers;   Former  Lecturer  on  Heat- 
ing  and    Ventilation,    Universtiy   of  Pennsylvania  and   Massachusetts 
Institute  of  Technology. 
J.  Harvey  Miller,  M.D. 

Formerly  Physician  Soldiers'  Home,  Dayton,  Ohio;    Physician  Dis- 
pensary Department,  Harrisburg  Hospital. 
Frank  Hedley,  Esq. 

Vice-president    and   General   Manager,    Interborough   Rapid    Transit 
Company,  New  York. 
Samuel  H.  Orwing,  A.M.,  LL.B. 


COLLABORATORS 

A  Committee  of  Fellows  of  the  HarrishurgAcademy  of  Medicine,  J.  Walter 
Park,  M.D.,  David  S.  Funk,  A.B.,  M.D.,  J.  W.  Ellenberger,  M.D. 

Allen  S.  Graham,  A.B. 

Gas  Engineer,  United  Gas  and  Improvement  Company. 

A.  M.  Cleland. 

General  Passenger  Agent,  Northern  Pacific  Railway  Company. 

A.  M,  Kepple. 

Superintendent,  The  Washington  Terminal  Company. 

A.   W.    GiBBS. 

General  Superintendent,  Motive  Power,  P.  R.  R. 

C.  C  Lacey. 

Marine  Superintendent  Great  Northern  Steamship  Company. 

J.  W.  Price. 

Chief  Engineer,  Atlantic  City  Sewerage  Company. 

Management,  The  Red  Star  Line. 

Chemical  Department,  H.  J.  Heinz  Company. 

Management,  Waldorf-Astoria  Hotel. 

Jos.  H.  Appel,  The  Wanamaker  Store. 

W.  Murrie,  Hershey  Chocolate  Company. 

Thos.   a.   Curry,  The  Larkin  Company. 


These  gentlemen  have  supplied  technical  and  commercial  information 
essential  to  the  preparation  of  the  volume. 


THE  FOLLOWING  INDIVIDUALS  AND  ORGANIZATIONS 

have  supplied  data,  reprints,  photographs,  etc.,  or  have  delegated  assistants 
to  aid  the  editor;  or  have  otherwise  actively  promoted  the  undertaking: 

The  Surgeons  General 

of  the  Army,  Navy,   and  the  Public  Health   and  Marine  Hospital 
Service,  United  States. 
Bureau  of  Chemistry, 

United  States  Department  of  Agriculture,  Dr.  H.  W.  Wiley,  Chief. 
U.  S.  Bureau  of  Animal  Industry. 
United  States  Department  of  Internal  Affairs. 
United  States  Post  Office  Department. 
The  Public  Health  Service,  Philippine  Islands  and  Canal  Zone. 
United  States  Immigration  Station,  Ellis  Island,  New  York  Harbor. 
Dr.  C.  C.  Grieve,  U.  S.  N.,  Sitka,  Alaska. 
Maj.  Chas.  Lynch,  Medical  Corps,  United  States  Army,  Washington,  D.  C . 

Secretary  and  Editor,   The  Association   of  Military   Surgeons  of  the 
United  States. 
Thomas  Darlington,  M.D.,  New  York  City. 

Late  Commissioner  of  Health,  New  York  City  Department  of  Health. 
Wm.  C.  Woodward,  M.D.,  Washington,  D.  C. 

Health  Officer,  District  of  Columbia. 
A.  H.  Doty,  M.D. 

Health  Officer,  Port  of  New  York. 
Office,  Commissioner  of  Corrections,  Neiu  York  City. 
State  Departments  and  Boards  of  Health. 

Of  nearly  all  of  the  States  and  Territories  of  the  United  States. 
Many  Local  and  City  Boards  of  Health. 
The  Laboratory  of  Hygiene,  University  of  Pennsylvania. 
Colorado  State  Bureau  of  Mines. 
Pennsylvania  Department  of  Mines. 
Thos.    R.    Crowder,   M.D.,    Superintendent   of  Sanitation,   The  Pullman 

Company,  Chicago. 
Chas.   B.  Dudley,  Ph.D.,  Lately  Chemist  P.  R.R.,  Altoona,  Pa. 
California  Board  of  State  Harbor  Commissioners. 
Wm.  Blair,  M.D.,  Ann  Arbor,  Mich. 
S.  M.  Shoemaker,  Eccleston,  Md. 

Wm.  Jennings,  Esq.,  President  Harrisburg  Board  of  Public  Works. 
Paul  A.  Hartman,  M.D.,  Dauphin  County  Inspector,  Pennsylvania  De- 
partment of  Health. 
Harold  R.  Jauss,  Harrisburg,  Pa. 

Many  Park  Boards,  Manufacturers,  Railroads,  Municipal  Officers, 
etc. 


CONTENTS 


PREFACE 

LIST  OF  CONTRIBUTORS 


Chapter  I 


THE  FAMILY  VS.  THE  COMMUNITY 1-7 

Provisional  quarantine  and  its  limitations  —  The  necessity  of  state 
regulation  —  Reporting  infectious  diseases  —  Local  regulation  of — Urgency 
of  special  cases  —  Rural  and  isolated  cases  —  Doubtful  cases  —  Mild 
forms  —  How  far  the  attending  physician  should  rely  upon  his  own  diagnosis 

—  State  and  other  experts  —  How  should  quarantined  families  be  main- 
tained ? —  Paucity  of  laws  regulating  this  matter  —  When  is  it  safe  for 
the  bread-winner  of  quarantined  families  to  work  ?  —  The  duties  of  con- 
sultants —  Concealed  cases  and  those  employing  no  physician. 

Chapter  II 

HOTELS,  LODGING  HOUSES  AND  PUBLIC  BUILDINGS     .         .     8-37 

Introductory  —  The  common  law  as  it  influences  the  question  —  Some 
consideration  of  the  laws  and  regulations  governing  hotels  and  lodging 
houses  —  Quarantine  in  hotels  and  public  buildings  —  The  problem  of 
the  modern  fiat  and  apartment  house  —  Summer  and  resort  hotels  —  The 
privileges  that  may  be  safely  allowed  to  isolate  a  case  in  a  hotel  or  public 
building  without  quarantine  of  the  entire  building  —  Transients  and  vital 
statistics  —  An  Example  of  a  sanitary  hotel  —  Specifications  for  public 
buildings  —  Office  buildings  and  infectious  cases  therein  —  The  large 
commercial  buildings  and  their  sanitation  —  Fire  hazard  and  sanitation  — 
An  example  —  Stores  —  Markets  —  Barber  shops  —  Laundries  —  Churches 
and  schools  —  Opera  houses  —  Industrial  establishments  —  Hygiene  and 
disinfection  of  large  buildings  —  Some  examples. 

Chapter  III 

SCHOOL  INSPECTION  AND  COLLEGE  SANITATION  .         .  38-57 

A  practical  presentation  of  the  duties  of  the  school  medical  inspector  and 
the  school  nurse  in  both  the  large  and  the  small  city  —  Exclusion  of  infec- 
tious cases  —  The  tuberculous  teacher  —  Defectives  and  degenerates  —  Sani- 
tation of  buildings  —  The  tobacco  problem  —  The  hygiene  of  athletic  sports 

—  Sexual  and  venereal  instruction  for  young  men  in  college  —  College 
training  in  sanitation  —  Nurses'  training  schools. 

Chapter  IV 

PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE        58-78 
The  bad  record  of  the  past  as  regards  jails  —  Some  present  bad  conditions 

—  Signs  of  improvement  —  Specializing  in  correction  —  Plans  tending 
toward  a  more  rational  treatment  of  crime  and  criminals  —  Some  instances  of 
correct  practice  —  Disease  in  prisons  —  The  special  hygiene  of  large  prisons 
• —  Of  smaller  prisons  —  The  tramp  question  —  Juvenile  offenders  —  The 


HYGIENE 

medical  service  of  prisons  —  Infectious  diseases  —  Some  general  con- 
siderations. 

The  Police — Their  service  to  the  public  —  Police  ambulances  —  The 
police  matron  —  The  sanitary  police  —  The  place  of  the  police  in  suppress- 
ing vice  —  Police  instruction  in  first  aid  —  Their  future. 

Insanity  and  its  care  in  the  broader  aspects  of  prevention,  the  sanitation 
of  institutions  and  the  general  care  of  perversions  and  moral  conditions  due 
to  insanity. 

Chapter  V 

MATERNITIES 79-92 

Introductory  —  Early      maternities    — Social    considerations  —  Modem 
institutions — Objections  urged  —  Illegal    maternities  —  Laws    regulating 
all  institutions  and  with  especial  reference  to   the    statutes    of    Ohio  — 
Ethical,  professional,  and  religious  considerations. 

Chapter  VI 

PLACES  OF  AMUSEMENT  AND  OF  DISSIPATION         .         .        92-114 
Opera   houses   especially   in   time   of  epidemic  —  Actors   and    actresses 
with  infectious  diseases  —  Small  amusement  halls,  rinks,  and  dance  halls 

—  Clubs  and  infectious  diseases  —  The  hygiene  of  liquor  and  narcotic 
addiction  —  Prostitution  and  what  the  general  practitioner  can  do  to  miti- 
gate its  evils  —  Our  duty  to  inmates  in  behalf  of  public  safety  —  The 
necessity  for  adequate  treatment  of  venereal  diseases  —  So-called  "  cer- 
tificates of  health." 

Parks  and  their  sanitation  —  Forest  reservations  —  Mountain  lands  — 
Salt  marshes  —  Mosquitoes  in  same  —  Closing  natural  waterways  —  Artifi- 
cial lakes  and  ponds  —  Municipal  parks  —  Parking  of  public  grounds — 
School  grounds  —  Pubhc  playgrounds  —  Amusement  parks  —  Expositions. 

Seaside  Resorts  and  their  sanitation  —  Boards  of  health  in  — Quaran- 
tine and  isolation  as  applied  at  Atlantic  City  —  Food  supply  —  Sewerage 

—  Garbage  —  Mosquitoes  and  flies  —  Water  supply  —  Bathing  estab- 
lishments —  Hospitals  —  The  death  rate. 

Chapter  VII 

SLUMS  AND  TOWN  NUISANCES     ......       115-126 

Building  laws  and  the  slums  —  What  we  should  and  may  expect  of  owners, 
tenants,  and  the  authorities  —  Inadequate  laws  in  many  places  —  Manure 
and  factory  refuse  —  The  smoke  evil  —  Stagnant  water — Public  dumps 

—  Dirty  vacant  lots  —  Weeds  —  Offensive  manufacturing  and  mine 
refuse  —  Other  nuisances  —  Rats,  fleas,  and  bubonic  plague. 

Chapter  VIII 

SPECIAL  RURAL  HYGIENE  AND  SANITATION     .         .         .      127-156 
Watersheds  and  rural  water  supply  —  Ice  supply  and  ice  ponds  —  Infected 
wells  —  Springs  —  Cisterns  —  Hauled  water  —  Tanks  and  piped  water  — 
Barnyard     drainage  —  Sewage  —  Vaults  —  Fertilizers  —  Sick     and     dead 
animals. 


TABLE  OF  CONTENTS 

Milk  Supply  and  the  many  questions  involved  therein  —  Cheese,  meat, 
and  milk  ptomaines  —  Butter  and  butter  substitutes  —  Creameries. 

Dressed  Meats  and  federal  inspection  —  Poultry  —  Eggs  —  Food  pre- 
servatives and  dyestufFs  —  Fish  and  game  meats. 

Insecticides  upon  food  —  Poisonous  plants  and  their  eradication  —  Insect 
pests  —  Sanitation  in  sending  produce  to  market  —  Summer  camps  — 
Rural  resorts. 

Chapter  IX 

STATE  DEPARTMENTS  AND  BOARDS  OF  HEALTH  .        157-251 

Introductory  remarks  —  An  outline  of  their  legal  basis  in  the  states  and 
territories  —  The  legal  powers  and  limitations  of  state  boards  of  health  — 
The  importance  of  keeping  up  with  the  regulations  in  force  in  one's  own  state 

—  What  obhgations  rest  upon  the  general  practitioner  —  The  vaccination 
problem  —  Reports  expected  of  physicians  —  Vital  statistics  —  Local 
representatives  of  state  organizations  —  Their  relationship  to  local  health 
boards  —  Misunderstandings  and  disputes  and  how  to  avoid  them  —  The 
charity  and  emergency  work  of  state  boards  and  how  the  physician  can  co- 
operate therein. 

Roster  of  States,  territories  and  dependencies  of  the  United  States, 
giving  an  account  of  the  organization  and  work  therein  —  Where  to  secure 
bulletins  and  regulations  —  Analysis  and  conclusions. 

Chapter  X 

A  PROPOSED  FEDERAL  BUREAU  OF  HEALTH  .  .  .  216-220 
What  the  government  at  Washington  is  now  doing  —  What  it  might  do  — 
Objections  to  a  national  department  but  little  to  a  bureau  —  What  such  a 
bureau  could  do  for  the  general  good  of  medicine  and  sanitation  —  The 
importance  of  international  hygiene  as  shown  in  Cuba  and  the  Canal  Zone  — 
What  the  army  and  navy  could  do  for  public  health  —  The  hygiene  of 
interstate  and  international  commerce. 

Chapter  XI 

LOCAL  BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  221-250 

Introductory  remarks  —  The  maze  of  laws  and  regulations  —  The  neces- 
sity of  informing  one's  self  regarding  local  regulations  —  The  relationship 
that  should  exist  between  the  officials  and  the  physicians  —  The  mistake  of 
shifting  all  authority  from  local  to  state  officials  —  City  bacteriologists  and 
chemists  —  Routine  duties  of  the  health  officer  discussed  under  several 
headings. 

City  Boards  as  a  separate  problem.  The  Washington  and  New  York  city 
departments  of  health. 

Chapter  XII 

ARMY  AND  NAVY  SANITATION;  OR  — HYGIENE  OF  CAMPS  251-274 
Introduction  —  Organization  —  Recruits  —  Hygiene  in  peace  —  In  war 

—  In  battle. 


HYGIENE 

Camps — Water  supply  —  Rations  —  Disposal  of  excreta  —  Housing  — 
Transmissable  diseases  —  Typhoid  —  Malaria  —  Diarrhoeas  —  Bubonic 
plague  —  Venereal  diseases  —  Other  infections  —  Special  tropical  dis- 
eases —  Clothing  —  Marches  —  The  canteen. 

Special  Naval  Regulations  —  To  enter  medical  service  of — Medical 
school  of —  Duties  of  medical  officers  —  Enlistment  —  Sanitary  regulations 
—  Quarantine  —  Insanity  in  Navy. 

Public  Health  and  Marine  Hospital  Service,  a  general  survey  of  its 
functions  and  the  work  it  has  done. 

Other  Camps  —  Contractor's  labor  camps  —  Camps  in  time  of  public  dis- 
aster —  The  lessons  the  general  practitioner  can  learn  from  the  army  and 
navy. 

Chapter  XIII 

THE  CORONER  AND  THE  PHYSICIAN 275-277 

A  discussion  of  his  statuts  in  law  —  The  importance  of  the  physician 
knowing  the  powers  of  the  Coroner  —  What  a  physician  can  expect  of  a 
coroner  —  What  a  coroner  can  expect  of  a  physician  —  What  cases  to  report 
to  the  coroner  —  Final  remarks. 

Chapter  XIV 

QUARANTINE  278-294 

Definitions  —  Maritime  —  Port  regulations  —  Inspection  —  Ports  of 
entry  —  Quarantining  of  vessels  —  Requirements  at  quarantine  —  Regula- 
tions concerning  cholera,  yellow  fever,  smallpox,  typhus  fever,  leprosy,  and 
plague  —  Canadian  and  Mexican  frontiers  —  Disinfection  —  Interstate  quar- 
antine —  Maritime  quarantine  maintained  on  lakes,  gulf,  and  rivers  — 
Inland  quarantine. 

The  States  —  Survey  and  tables  of  the  quarantine  regulations  in  force  in 
the  various  states  and  territories. 


Chapter  XV 

INFECTIOUS  DISEASES 295-310 

Introductory  remarks  —  Tables  giving  incubation,  mode  of  onset,  occur- 
rence of  eruption,  character  of  eruption,  fading  or  disappearance  of  erup- 
tion, duration  of  illness,  character  of  other  symptoms  and  phenomena,  mode 
of  contagion,  and  period  of  contagion. 

Methods  in  use  by  physicians  to  protect  themselves,  their  families,  their 
patients,  and  the  public. 


PLATE  ILLUSTRATIONS 


Volume  I 


A  Park  Lake,  Formerly  a  Malarial  Swamp,  a  Shallow  Lake  Choked  with  Weeds  —  A 

Properly  Constructed  Artificial  Lake frontispiece 

GPP.  PAGE 

A  Filthy  Stream  in  a  Large  City 4 

Two  Insanitary  Alleys 4 

Parking  Concealing  a  Coal  Pit 14 

Ideal  Apartment  Houses 14 

A  Street  of  Apartment  Houses,  New  York  City 14 

Surgeon's  Room,  Waldorf-Astoria  1 l8 

Elevator  Entrance  to  Rest  Room  1 l8 

New  Union  Depot,  Washington,  D.  C.  2 22 

Heating  and  Power  Plant,  under  a  Paved  Area    22 

Public  Building  Marooned 22 

Model  Sanitary  Office  Building  3 j4 

Central  Skylighted  Court  of  Above  ^     34 

Large  Office,  Administration  Building  3     , ,  _  35 

Reading  Room  for  Employees  ^     36 

University  of  Michigan  Gymnasium 48 

School  Nurse  at  Work  4 48 

Medical  College,  Anatomical  Laboratory 48 

Cell  Corridor,  "The  Tombs"  Prison 62 

Portion  of  the  Kitchen 62 

Part  of  Yard 62 

Police  Automobile  Ambulance  Service 68 

Automobile    68 

Michigan  State  Psychopathic  Hospital,  Ann  Arbor  5 76 

Portion  of  "The  Tombs"  Prison,  New  York  City 76 

Lying-in  Hospital,  New  York  City  6 82 

Harrlsburg  Park  Views  —  Lily  Pond  Water  Works  Park 92 

Automatic  Sanitary  Spill- Way  at  Dam,  Wildwood  Park 92 

Riverside  Parkway 92 

Botanical  Garden,  Washington  ^ lOo 

House  of  Public  Comfort lOO 

Park  Museum,  Fairmount  Park lOO 

Young  Athlete's  Paradise 108 

Where  the  Unfortunate  Often  Sleep 108 

Bear's  Den,  Zoological  Garden,  Philadelphia 108 

Sewerage  Plant,  Atlantic  City  8 II2 

Locker  Room,  Sanitary  Bath  House  ^   1 12 

Ideal  Rural  Water  Supply 132 

Uncontaminated  Stream  Supply 132 

Farm  Spring  Effectively  Protected 132 

Ideal  Dairy  Conditions  ^ 140 

Pumping  River  Coal 156 

Abandoned  Canal 156 

Machine  for  Drilling  Deep  Wells 156 

Michigan  Laboratory  of  Hygiene 212 

Medical  Missionary  Work  in  the  Tropics  10 212 

Municipal  Crematorium,  District  of  Columbia  1^ 228 

Smallpox  Hospital,  at  Above  H 228 

Public  Comfort  Station,  Washington,  D.C.  H 240 

Reception  Hospital,  Department  of  Health,  New  York  City  4 250 

Scarlet  Fever  Building  * 250 


PLATE  ILLUSTRATIONS 

OPP.  PAGE 

Administration  Building  ^ ^  2C0 

Dressing  Station  and  First  Aid  Work,  Camp  Tacoma  12 256 

Camp  of  Instruction  and  Provisional  Tent  Hospital  12 264 

Another  Portion,  same  Camp  12 264 

Field  Hospital  and  Ambulance  Company  12 264 

Marine  Hospital  Sanatorium,  Fort  Stanton,  New  Mexico  13 274 

Boat  Landing,  Offices,  and  Laboratory  —  Quarantine  Station,  Staten  Island 282 

Savannah  Quarantine  Station  14 292 

Cape  Fear  Quarantine  Station  14^ 292 

Two  Views  Municipal  Hospital,  Atlantic  City  9 292 


TEXT  ILLUSTRATIONS 


Volume  I 


PAGE 

Dark  Prison  of  the  Old  and  Insanitary  Type 60 

A  Farm  Filter j^i 

Rider  and  Ericsson  Hot  Air  Pumping  Engines 134 

Plan  for  House  Drainage 136 

Revision,  from  Illustrations  in  the  Typhoid  Issue  of  the  Virginia  Health  Bulletin 137 

A  Few  Common  or  Dangerous  Weeds 153 

From  the  Mud  Taken  from  a  Mountain  Brook 155 

Your  Turn  Next 207 

How  High  is  the  Wall  in  Your  Town 207 

The  Hemisphere  of  our  Health  Work 208 

Public  Comfort  Station,  Washington,  D.  C 241 


ACKNOWLEDGMENT 

The  author  and  publisher  wish  to  express  their  thanks  to  those  through  whose  courtesy,  as 
indicated  below,  many  of  these  illustrations  are  used. 

1  Management,  Waldorf-Astoria  Hotel. 

2  From  Steel  Engraving,  The  Washington  Terminal  Company. 

3  The  Larkin  Company. 

*  Department  of  Health,  New  York  City. 

5  William  Blair,  M.D.,  Ann  Arbor. 

^  Lying  In  Hospital,  New  York. 

7  J.  A.  Kepple,  Harrisburg,  Pa. 

8  W.  Blair  Stewart,  A.M.,  M.D.,  Atlantic  City, 

9  S.  M.  Shoemaker,  Eccleston,  Maryland. 

10  J.  S.  Grant,  M.D.,  Ningpo,  China. 

11  Wm.  C.  Woodward,  M.D.,  Health  Officer,  District  of  Columbia. 

12  United  States  War  Department. 

13  P.  M.  Carrington,  Surgeon,  United  States  Public  Health  and  Marine  Hospital  Sen-ice. 

14  United  States  Public  Health  and  Marine  Hospital  Service. 
Other  photographs  and  drawings  by  the  author. 


PUBLIC   HYGIENE 


Chapter  I 
THE  FAMILY  VERSUS  THE  COMMUNITY* 

IT  is  perhaps  no  exaggeration  to  say  that  in  no  other  period  of  history  has 
the  prevention  of  disease  occupied  so  large  a  place  in  the  thoughts  of 

every  intelligent  community  as  obtains  at  this  present  day.  Organiza- 
tions of  intelligent  men  and  women  exist  in  all  of  the  large  centers  of  popula- 
tion whose  sole  aim  and  purpose  is  the  conservation  of  the  public  health. 
Their  time  and  means  are  freely  given  to  the  end  that  their  fellows,  of  every 
class  and  condition,  may  not  only  be  nursed  back  to  health  when  they  fall  ill, 
but  that  their  wellbeing  may  also  be  preserved  by  a  healthful  environment, 
and  pure  and  wholesome  food,  in  order  to  limit  disease  they  may  contract, 
avoid  unnecessary  ailments,  and  prolong  their  lives  to  their  families  and 
society. 

No  man  is  or  can  be  "  a  law  unto  himself,"  but  is,  in  a  large  sense,  his 
brother's  keeper.  Individualism  must  be  submerged  in  order  that  every 
human  unit  in  every  place  have  a  community  of  interest  with  every  other. 

The  early  recognition  and  isolation  of  communicable  disease  is  the  first 
step  in  this  splendid  movement;  the  discovery  of  its  cause  and  its  complete 
eradication,  the  next  one.  So  brilliant  have  been  recent  achievements  along 
this  line  as  to  constitute  an  epoch  in  the  world's  medical  history.  Nor  is  this 
the  end,  but  rather  only  the  beginning;  for  it  is  entirely  fair  to  assume  that 
prophylaxis  will  prevail  so  successfully  as  to  be  the  crowning  glory  of  the 
twentieth  century.     All  men  love  liberty,  but  they  love  life  more. 

It  happens  as  a  logical  sequence  that,  when  life  is  at  stake,  it  may  be 
necessary  to  curtail  liberty  in  order  to  safeguard  or  preserve  existence.  The 
medical  men  of  long  ago  recognized  the  fact  of  the  transmission  of  certain 
diseases,  but  the  medium  of  contagion  was  a  fruitful  theme  for  discussion 
and  dissension.  Our  own  Oliver  Wendell  Holmes  and  Semmelweis,  of 
Vienna,  both  taught  that  puerperal  fever  was  communicable,  but  the  pro- 
fession at  large  was  slow  to  accept  the  dictum  and  the  disease  continued 
to  reap  its  harvest.  So  likewise  was  yellow  fever  known  to  be  contagious, 
but  it  remained  for  Reed,  Lazear,  Carroll,  and  Agramonte  to  demonstrate 
how  it  became  so.  It  would  be  impossible  to  estimate  the  far-reaching  results 
for  good  that  such  discoveries  have  brought  to  pass  in  presenting  convincingly 
to  the  intelligent  lay  mind  the  value  of  medical  research  work. 

The  endorsement  by  laymen  of  the  various  men  and  means  necessary 
to  effective  sanitation  has  been  accomplished  by  such  definite  demonstra- 
tions as  are  these.  The  doubt  and  distrust  of  empiricism  have  given  way  to 
the  co-operation  and  confidence  engendered  by  demonstrated  science. 

Among  the  modern  measures  none  is  of  more  vital  importance  than  is 
the  early  establishment  of  quarantine.  Centuries  before  the  Christian  era 
attempts  were  made  along  this  line  with  the  hope  of  staying  the  ravages  of 
certain  dreaded  diseases,  the  Hebrews  and  their  attempted  isolation  of 
leprosy  being  a  striking  case  in  point. 

*By  David  S.  Funk,  A.B.,  M.D. 


2  HYGIENE 

Provisional  quarantine  and  its  limitations. —  While  the  maintenance  of  a 
legal  quarantine  is  to  be  preferred  under  most  circumstances,  yet  occasions 
arise  in  which  such  quarantine  either  cannot  exist  or  cannot  be  enforced. 
The  special  article  upon  Seaside  Resorts,  in  Chapter  VI,  is  an  instance  in 
point.  Aside  from  such  instances  where  business  policy  is  the  dominating 
factor,  there  are  areas  of  the  country  destitute  of  any  public  sanitary  admin- 
istration. Nevada  has  been  without  health  boards,  and  whole  counties  in 
the  interiors  of  some  Southern  states  have  not  been  organized  effectively. 
In  remote  lumber  camps,  in  some  of  the  turpentine  camps  of  the  South,  and 
in  contractors'  labor  camps  in  unsettled  regions,  as  well  as  in  the  gold  fields 
of  Alaska,  quarantine  is  largely  a  matter  which  devolves  upon  the  physicians 
in  charge.  The  United  States  navigation  laws  place  certain  sanitary  respon- 
sibility upon  the  masters  of  vessels,  who  usually  provide  sick  bays  and  author- 
ize the  surgeon  of  the  ship  to  maintain  a  quarantine.  Surgeons  employed  in 
camps  and  by  corporations  have  large  discretion  in  matters  of  quarantine. 
Yet  all  such  quarantine  measures  are  only  provisional  and  imperfect. 

A  lawyer  who  is  admitted  to  the  bar  is  considered  an  officer  of  the  court. 
In  the  same  sense,  a  physician  who  is  licensed  to  practice  has  a  legal  status 
in  his  state  that  surely  warrants  him  in  protecting  the  community  in  case  of 
danger  from  disease.  In  the  Journal  of  the  American  Medical  Association, 
for  November  20,  1909,  appeared  an  article  upon  epidemic  anterior  polio- 
myelitis in  Minnesota,  and  in  which  it  is  stated  that  over  fifty  epidemics  of 
this  disease  have  been  reported.  This  is  not  one  of  the  reportable  diseases 
in  Pennsylvania,  yet,  were  I  to  encounter  it  here,  my  provisional  quarantine 
of  the  case  would  doubtless  be  upheld  by  the  department  of  health  if  upon 
investigation  my  diagnosis  were  confirmed.  In  a  sense  all  quarantine  by 
attending  physicians  is  merely  provisional,  and  we  should  confess  to  a  feeling 
of  relief  that  the  state  takes  up  the  work  for  us  and  endeavors  to  make  effec- 
tive the  necessary  protective  measures  so  liable  to  bring  an  unsupported 
physician  into  unpleasant  conflicts. 

It  is  where  the  state  does  not  impose  an  adequate  quarantine  that  the 
physician  is  in  the  greater  difficulty  and  sustains  the  greatest  responsibility. 
In  reporting  a  case  of  smallpox  to  the  board  of  health  my  legal  status  is  the 
same  as  when  I  "  pull  "  a  fire  alarm  box;  a  false  alarm  alone  makes  me  re- 
sponsible. Possibly  a  case  of  contagion  is  not  so  easy  of  diagnosis  as  is  a  fire, 
but  the  diagnosis  or  discovery  of  both  are  equally  important  to  the  commun- 
ity. But  if  I  discover  a  small  fire  in  the  midst  of  the  wilderness  it  is  my 
responsibility  to  isolate  and  to  limit  it  by  any  and  all  means  within  my  power. 

Inasmuch  as  the  general  good  health  of  any  community  is  its  very  best 
asset,  it  is  incumbent  upon  the  commonwealth  to  inaugurate  such  measures 
as  seem  to  its  citizens  to  be  necessary  to  prevent  the  invasion  of  disease,  and 
to  permit  localities  so  situated  as  to  be  geographically  liable  to  unusual 
danger,  to  institute  special  regulations,  such  as  have  been  found  necessary  by 
New  Orleans  to  keep  out  yellow  fever,  and  by  San  Francisco  to  protect  the 
Occident  from  the  oriental  bubonic  plague.  As  the  "  Sovereign  States  "  are 
now  looking  to  the  federal  government  to  do  its  share  in  interstate  and  inter- 


THE  FAMILY  vs.  THE  COMMUNITY  3 

national  sanitation,  so  they  also  expect  every  man  to  do  his  duty.  Any  citizen 
with  a  flag  may  nail  it  to  the  pole  or  take  possession  of  an  unexplored  region 
in  the  name  of  his  government;  so  any  physician  can  raise  the  yellow  flag 
of  quarantine  pending  the  arrival  of  the  health  officer.  And  it  is  his  human 
and  professional  duty  to  take  the  initiative  where  the  circumstances  are  such 
as  to  preclude  adequate  official  service. 

Reporting  infectious  diseases. —  As  will  be  noted  in  the  latter  portion  of 
the  chapter  upon  quarantine,  all  of  the  organized  states  require  attending 
physicians  to  report  certain  communicable  diseases  or  be  subject  to  certain 
penalties  for  their  neglect.  This  is  a  decided  step  in  advance  of  the  condi- 
tions which  obtained  only  a  few  years  ago,  when  the  state  had  little  expressed 
voice  in  the  matter,  and  when  the  limited  authority  was  all  vested  in  the 
boards  of  county  commissioners  or  directors  of  the  poor.  It  is  only  necessary 
to  note  this  former  state  of  affairs  to  fully  appreciate  the  utter  lack  of  S}'Stem 
resulting  from  such  proceduie  as  compared  with  that  which  exacts  of  the 
physician  in  charge  a  prompt  and  full  report  to  the  proper  authorities  of  such 
cases  of  infectious  disease  as  may  come  under  his  care.  The  general  dissemi- 
nation of  knowledge  upon  all  matters  the  laity  require  in  order  to  appreciate 
the  operation  of  and  necessity  for  public  health  administration,  is  rapidly 
converting  them  to  approval  of  measures  formerly  misunderstood  and  some- 
times resisted.  Hence,  reporting  is  becoming  a  less  disagreeable  duty  to  the 
physician.  Reporting  infectious  diseases  aims  at  two  objects,  the  first  being 
the  protection  of  the  public,  and  the  second  the  collection  of  vital  statistics. 
The  first  object  is  the  more  immediate  one,  yet  it  is  to  be  feared  physicians 
do  not  fully  appreciate  the  value  of  the  second  one. 

Publicity  is  the  modern  cure  for  many  evils;  among  them  disease  looms 
large  and  its  existence  should  be  made  a  subject  of  common  knowledge  to 
the  end  that  precautionary  measures  may  be  early  instituted  of  such  a  char- 
acter as  will  aff^ord  the  maximum  of  protection  with  the  minimum  of  incon- 
venience. To  accomplish  this,  organization  is  essential  and  boards  of  health 
a  necessity.     To  be  effective,  they  must  be  vested  with  due  legal  authority. 

Vital  statistics  are  impossible  without  professional  reports  giving  the 
data  necessary  to  the  making  up  of  the  mortality  rate  and  the  number  and 
character  of  infectious  cases.  But  reports  accomplish  more  than  this;  that 
is  to  say  the  presence,  in  a  more  or  less  continued  way  or  endemicall}^,  of 
communicable  diseases  is  prima  facie  evidence  of  unpardonable  supineness 
or  even  lack  of  intelligence  upon  the  part  of  some  one.  Provided  physicians 
make  proper  and  prompt  reports,  the  fault  cannot  be  theirs,  but  rather  that 
of  the  community  or  of  its  authorities.  As  a  striking  illustration,  one  need 
but  recall  the  very  insanitary  condition  of  Havana  and  Santiago  under  Span- 
ish rule  and  involving  a  frightful  mortality  from  yellow  fever  and  other  infec- 
tious diseases.  Nor  were  our  own  military  camps  in  the  United  States  during 
the  Spanish  American  War  very  much  better  so  far  as  relates  to  the  mortality 
from  typhoid  fever.  Our  later  more  favorable  reports  from  our  tropical 
service  aie  due  to  measures  outlined  in  the  chapter  in  this  book  upon  military 
hygiene,  and  emphasize  the  fact  that  eternal  vigilance  is  the  price  of  sanitary 


4  HYGIENE 

success.  Vital  statistics  suggested  the  reforms  in  camp  life  and  are  as  neces- 
sary in  civil  affairs,  for  a  city  is  but  a  permanent  camp.  Indeed,  the  intelli- 
gence of  a  community  can  be  somewhat  gauged  by  its  care  or  its  lack  of  care 
in  the  collection  of  vital  statistics. 

Urgency  of  special  cases. —  While  the  usual  reports  are  alv?ays  desirable, 
especial  urgency  occurs  in  the  case  of  invasions  of  smallpox,  cholera,  yellow 
fever,  bubonic  plague,  and  other  rapidly  disseminated  infections.  Many 
epidemics  have  resulted  from  tardy  reports,  and  it  is  essential  that  the  tele- 
phone and  telegraph  be  used  and  are  none  too  rapid  for  reports  in  urgent 
cases  or  in  those  of  marked  danger.     Some  states  require  such  reports. 

Rural  and  isolated  cases. —  Special  risks  and  dangers  attend  these  classes 
of  contagious  disease.  Their  isolated  environment  are  calculated  to  beget 
upon  the  part  of  the  family  and  the  medical  attendant  a  disinclination  to  hew 
strictly  to  the  line  in  the  many  little  details  essential  to  the  prevention  of  dis- 
ease dissemination.  The  comparatively  recent  epidemic  of  typhoid  at  Ply- 
mouth, Pennsylvania,  brings  forcibly  to  mind  the  terrible  amount  of  harm 
which  may  result  from  a  single  case  of  this  disease  when  disinfection  of  the 
excreta  has  been  neglected.  Watersheds  are  thus  contaminate  and  entire 
villages  and  towns  are  brought  face  to  face  with  serious  epidemics.  The 
milk  supply  has  frequently  been  the  means  of  one  case  of  scarlet  fever  result- 
ing in  a  severe  epidemic,  and  London,  Philadelphia,  and  other  large  cities  have 
furnished  striking  instances.  Viewed  in  the  light  of  dreadful  experiences,  one 
can  readil}-  appreciate  the  rather  larger  responsibility  of  the  physician  in 
attendance  upon  the  rural  or  isolated  case  than  obtams  with  the  city  physician 
who  may  have  at  his  beck  and  call  all  the  machineiy  of  a  well-organized  and 
fully  equipped  board  of  health.  With  the  latter  upon  the  reporting  of  the 
case  come  certain  restrictions  which  will  probably  prevent  further  spread  of 
the  disease,  whereas  in  the  case  of  the  former  physician  the  fight  is  single 
handed  and  with  probably  greater  precautions  necessary.  Wells,  cesspools, 
streams,  schools,  dairies,  and  other  factors  may  all  devolve  upon  him,  and  it 
behooves  the  country  practitioner  to  be  Ytvy  circumspect  in  his  management 
of  all  cases  of  communicable  disease,  and  he  must  be  politic  in  enforcing  proper 
hygienic  practice  to  prevent  a  widespread  epidemic  being  due  partially  to  his 
own  lack  of  care  and  education  of  his  families  and  the  community. 

Doubtful  cases. —  In  the  irregular  cases  of  the  eruptive  fevers,  it  is  fre- 
quently a  matter  of  no  little  difficulty  to  make  an  early  diagnosis.  In  all 
such  cases  there  can  be  but  one  proper  line  of  conduct  for  the  attending  phy- 
sician, viz.,  isolate  the  patient  from  the  very  first,  since  it  is  better  to  slightly 
inconvenience  the  family  than  to  subject  the  community  to  danger.  One 
need  not  report  the  case  until  after  he  is  able  to  make  a  diagnosis  unless  an 
undue  period  of  doubt  justifies  calling  a  consultant  or  an  experienced  medical 
health  officer. 

Mild  forms. —  The  seeming  mildness  of  any  form  of  communicable  dis- 
ease should  not  have  any  weight  whatever  against  the  advisability  of  quar- 
antine providing  the  attending  physician  has  just  ground  for  suspecting  the 
real  nature  of  the  case.     These  are  the  very  cases,  however,  that  are  well 


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A    FILTHY    STREAM    IN    A    LARGE    CITY 

Such  Streams  are  a  difficult  problem.     Much  effort  and  money  has  been 
expended  upon  this  one,  but  it  is  still  insanitary. 

One   side   of   this    alley   faces    the  This  alley  is  not  in  a  large  city, 

rear  of  large  stores  and  hotels;    the      and  instances  land  greed  on  one  side 
other  side,  stables  and  saloons.  and  tuberculosis  on  the  other  side. 


THE  FAMILY  vs.  THE  COMMUNITY  5 

calculated  to  make  him  very  unpopular  with  the  involved  families,  since  they 
do  not  understand  the  danger  of  mild  cases  engendering  the  most  virulent 
type  of  the  disease  in  other  individuals.  Nor  has  the  medical  attendant  done 
anything  like  his  full  duty  to  himself,  the  family,  or  the  community,  until 
after  he  has  taken  the  time  to  fully  explain  the  absolute  necessity  of  main- 
taining quarantine  over  communicable  disease  without  regard  to  the  apparent 
mildness  of  the  attack.  The  more  intelligent  element  of  society  is  quick  to 
understand  the  import  of  quarantine,  but  the  less  informed  must  be  edu- 
cated along  such  lines  by  the  rank  and  file  of  general  practitioners.  This 
requires  patience  and  that  the  doctor  tactfully  controvert  preconceived  ideas 
and  prejudices  that  are  very  natural.  Neither  health  officers  nor  physicians 
in  attendance  upon  cases  can  afford  to  be  arbitrary  or  dictatorial  to  persons 
who  feel  that  their  rights  are  being  involved  without  due  process.  It  is  here 
that  the  physician  can  do  an  excellent  educational  work  that  will  greatly  aid 
the  health  boards. 

How  far  the  attending  physician  should  rely  upon  his  o%vn  diagnosis. — 
In  the  matter  of  communicable  disease  it  is  of  the  utmost  importance  that  a 
correct  diagnosis  be  made  at  the  earliest  possible  moment.  This  is  so  uni- 
versally conceded  that  it  would  seem  scarcely  necessary  to  make  mention  of 
it  here.  But  when  one  recalls  that  errors  of  the  most  serious  nature  and 
fraught  with  very  unpleasant  consequences  have  arisen  in  the  past  and  are 
still  arising  in  most  unexpected  quarters,  it  would  seem  that  a  word  along  this 
line  might  be  admissible.  So  long  as  smallpox  is  mistaken  for  "  Cuban  itch," 
and  fatal  cases  of  diphtheritic  croup  for  "  tonsillitis  with  suffocation,"  and 
appendicitis  for  typhoid  fever,  it  would  seem  that  some  general  practitioners 
may  at  least  have  their  limitations  He  should  not  be  too  hasty  in  forming 
an  opinion  in  a  case,  a  similar  one  of  which  he  may  never  have  seen. 

Errors  in  diagnosis  are  bound  to  occur,  but  so  long  as  disease  is  of  a 
nature  which  is  not  communicable,  the  community  is  not  endangered  and  no 
great  harm  may  be  done.  With  infectious  diseases  the  clinical  features  may 
be  so  plain  as  to  make  early  diagnosis  easy;  but  the  onset  of  the  disease  may 
follow  an  irregular  or  unusual  type  and  perhaps  one  never  previously  seen 
by  the  medical  attendant,  or  new  to  his  locality  and  requiring  a  bacteriological 
examination  to  determine  its  real  character.  Especially  in  seaport  towns  into 
which  the  germs  of  diseases  from  remote  sections  are  extremely  likely  to  be 
imported,  despite  efficient  quarantine  regulations,  is  the  general  practitioner 
apt  to  encounter  these  irregular  or  little  seen  diseases.  Naturally,  his  duty 
is  to  notify  the  quarantine  officer  instead  of  depending  solely  upon  his  own 
diagnosis.  And  in  any  event,  it  behooves  the  medical  attendant  to  recognize 
his  limitations  and  to  avail  himself  of  such  expert  counsel  as  is  almost  always 
available,  especially  since  nearly  all  state  boards  of  health  make  it  their  care 
to  supply  laboratory  and  other  diagnostic  aids. 

How  should  quarantined  families  be  maintained? —  A  family  under  rigid 
quarantine  may  be  entirely  deprived  thereby  of  its  bread-winning  capacity. 
It  happens  not  infrequently  that  the  maintenance  of  such  persons  becomes  a 
matter  of  serious  concern.     At  first  blush,  it  might  seem  that  a  legal  regula- 


6  HYGIENE 

tion  which  deprives  the  bread-winner  of  exercising  that  function,  while  phy- 
sically able  and  willing  to  do  so,  should  reimburse  him,  at  least  in  part,  for  the 
loss  of  time  and  money  entailed.  The  fallacy  of  such  logic  becomes  at  once 
apparent,  however,  when  it  is  borne  in  mind  that  these  same  restrictions  which 
now  apply  to  him  and  are  protecting  his  neighbors  and  fellow  workmen,  may 
have  safeguarded  himself  and  his  family  in  the  past  and  stand  ready  to  do  so 
again  in  the  future. 

Quarantine  so  limits  the  spread  of  communicable  disease  that  the  time 
and  wages  lost  are  a  small  item  compared  to  the  general  conservation  of 
health  and  industrial  activity  gained  thereby.  If  this  is  true  to  society  at 
large  it  is  equally  true  to  its  units. 

The  state  of  Maine  makes  certain  legal  provision  for  the  support  of 
families  under  quarantine,  but  the  states  at  large  have  not  admitted  the 
legality  of  this  especial  claim.  The  paucity  of  laius  regulating  this  matter 
makes  it  questionable  as  to  whether  the  state  should  be  asked  to  contribute  to 
one  class  of  individual  or  family  poverty  when  all  other  classes  come  under 
the  supervision  and  become  the  charge  of  counties  or  municipalities.  As  to 
the  maintenance  of  a  quarantined  family,  two  points  are  to  be  considered: 
first,  the  urgent  need  of  the  family;  second,  the  element  of  quarantine  itself. 
It  is  always  to  be  borne  in  mind  that  quarantine  calls  attention  in  a  forcible 
way  to  the  needs  of  the  families  so  involved,  and  both  city  and  rural  hearts 
respond  to  the  call  so  readily  that  there  is  but  little  real  occasion  for  real 
suffering  or  deprivation  made  necessary  by  reason  of  the  fact  that  the  com- 
munity at  large  is  being  protected  by  quarantine  regulation.  It  is  rare 
indeed  but  that  the  families  find  coming  to  their  support  such  redress  as  the 
exigencies  of  the  case  would  seem  to  demand. 

Some  well-organized  plan  to  relieve  the  immediate  necessity  of  the  de- 
serving poor  when  taken  down  by  illness  of  whatsoever  kind  is  needed  in 
every  considerable  community,  rural  or  urban.  That  is  to  say,  the  deserving 
poor  merit  the  charity  of  the  community  at  all  times,  but  more  especially  when 
they  become  ill;  not  so  much  because  the  illness  may  be  of  a  character  which 
requires  the  enforcement  of  quarantine  regulations,  but  because  they  are  poor. 

When  IS  it  safe  for  the  bread-winner  of  quarantined  families  to  work? — 
This  question  cannot  be  answered  offhand.  In  Chapter  II  there  is  some 
discussion  of  the  matter  as  applies  to  apartment  houses,  while  the  chapters 
upon  local  boards  of  health,  quarantine,  disinfection,  etc.,  all  throw  light 
upon  the  subject.  The  duties  of  consultants  is  a  touchy  matter,  discussed  in 
the  chapter  upon  local  boards,  and  need  not  be  entered  into  here,  although 
allied  to  this  subject. 

Concealed  cases  and  those  employing  no  physician. —  It  is  certainly  a 
regrettable  fact  that  an  occasional  physician  so  far  forgets  the  real  significance 
of  his  high  calling  as  to  be  a  party  to  an  attempt  at  concealment  of  communi- 
cable disease.  The  motive  for  such  concealment  is  nearly  always  the  same, 
and  aims  no  higher  than  the  obtaining  of  a  certain  though  surely  very  ques- 
tionable popularity  with  the  family  in  which  the  disease  may  happen  to  occur. 
There  are  to  be  found  in  almost  any  community  a  few  people  who  are  selfish 


THE  FAMILY  vs.  THE  COMMUNITY  7 

and  inconsiderate  enough  to  insist  that  they  shall  be  exempt  from  the  restric- 
tions of  quarantine,  and  they  hold  out  to  the  medical  attendant  all  manner  of 
bribes  and  inducements,  to  the  end  that  he  may  fall  into  line  with  their  way 
of  thinking.  Failing  in  this,  they  threaten  the  attendant  with  immediate  dis- 
missal, and  frequently  do  actually  dismiss  him,  presuming  usually  to  be  able 
to  secure  the  services  of  a  physician  who  will  have  a  conscience  sufficiently 
pliable  to  totally  ignore  his  predecessor's  diagnosis  and  thus  ingratiate  him- 
self into  the  good  graces  of  the  family  in  question.  With  such  physicians, 
diphtheria  is  never  anything  worse  than  "  sore  throat  "  or  "  tonsillitis,"  and 
scarlet  fever  becomes  "  rose  rash  "  or  an  "  erythematous  rash,"  or  some 
other  high-sounding  name.  Of  course  men  of  this  stamp  are  very  largely 
in  the  minority,  but  they  are  to  be  found  and  they  sometimes  crop  up  in  most 
unexpected  quarters. 

In  those  instances  in  which  the  physician  is  dismissed  from  the  case 
because  of  his  making  a  diagnosis  which  means  quarantine,  the  remedy  is 
easy  of  application.  It  simply  requires  that  the  physician  first  called  in  the 
case  report  the  matter  to  the  health  authorities,  who  will  make  the  proper 
investigation.  In  such  events  the  physician  should  avoid  controversy,  simply 
reporting  that  in  his  opinion  a  certain  communicable  disease  exists,  and  ever 
bearing  in  mind  the  possibility  of  error  upon  his  own  part. 

In  the  absence  of  an  organized  board  of  health  and  more  especially  in 
those  cases  where  the  attendant  first  called  is  willing  to  stoop  to  concealment, 
or  where  no  physician  is  employed,  the  problem  becomes  very  much  more 
complex  and  more  difficult  of  solution.  Mild  cases  of  scarlet  fever  are  par- 
ticularly prone  to  be  a  source  of  contagion  because  of  no  physician  having 
been  called,  unless,  perchance,  scarlatinal  nephritis  or  some  other  complica- 
tion arises  late  in  the  disease  and  is  accompanied  by  symptoms  which  alarm 
the  parents.     Every  general  practitioner  can  recall  cases  of  this  kind. 

As  to  the  laity,  the  correction  of  this  evil  must  be  left  largely  to  the  cul- 
tivation of  a  higher  ethical  point  of  view  as  regards  their  sanitary  and  other 
duties  toward  their  neighbor.  To  this  end,  the  family  medical  adviser  can 
accomplish  much  by  taking  a  high  point  of  vantage  as  regards  all  sorts  of 
deception  or  subterfuge  and  leading  his  patients  up  to  it  as  a  civic  and  per- 
sonal duty.  He  who  stands  upon  this  height  should  beckon  the  weaker 
brother,  and  probably  the  best  way  to  maintain  sanitary  virtue  is  through 
joining  with  and  maintaining  the  high  ideals  characterizing  medical  societies. 
The  free  commingling  of  the  medical  men  of  every  community  and  their 
combining  to  accomplish  the  things  looking  tOAvard  their  betterment  will  have 
as  an  end  resultant  the  sanitary  betterment  of  the  whole  community  and  the 
elimination  of  abuses  such  as  have  been  described.  Add  to  this,  publicity, 
the  modern  panacea  for  most  abuses,  and  they  will  cease  to  exist. 

The  old  Hippocratic  Oath  was  good.  It  made  good  and  honorable  men 
alone  seek  the  sacred  trust  of  family  doctor.  But  that  oath  must  to-day  be 
extended.  No  longer  are  we  interested  only  in  "  our  families."  We  now 
know  that  "  God  has  made  of  one  family  all  men  who  dwell  upon  the  face  of 
the  whole  earth,"  and  to  them  all  must  we  preach  the  gospel  of  sanitation  and 
right  living. 


Chapter  II 

HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS 

Introductory. —  The  common  law  as  it  influences  the  question  —  Some  consid- 
eration of  the  laws  and  regulations  governing  hotels  and  lodging  houses — Quarantine 
in  hotels  and  public  buildings  —  The  problem  of  the  modern  flat  and  apartment  house. 
Summer  and  resort  hotels — The  privileges  that  may  be  safely  allowed  to  isolate  a  case 
in  a  hotel  or  public  building,  without  quarantine  of  the  entire  building — Transients 
and  vital  statistics  —  An  example  of  a  sanitary  hotel  —  Specifications  for  public  build- 
ings—  Ofiice  buildings  and  infectious  cases  therein  —  The  large  commercial  buildings 
and  their  sanitation  —  Fire  hazard  and  sanitation  —  An  example  —  Stores  —  Markets 
—  Barber  shops- — Laundries  —  Churches  and  schools  —  Opera  houses  —  Industrial 
establishments  —  Hygiene  and  disinfection  of  large  buildings  —  Some  examples. 

"  /I  MAN'S  house  is  his  castle,"  and  for  a  long  time  it  was  regarded 
/~\  as  no  one's  affair  what  went  on  therein.  House  waste,  disagreeable 
things,  and  undesirable  inmates  were  simply  turned  into  the  street. 
The  house  was  surrounded  with  a  high  wall  and  one  was  safe  therein  from  all 
except  the  robber  and  the  visitations  of  offended  gods  or  the  "  dispositions 
of  Divine  Providence."  But  one  went  abroad  at  his  peril  and  carried  a 
lantern  and  side  arms  and  avoided  unclean  streets  by  taking  carriage  or  a 
horse.  And  the  "  tavern  "  or  "  hostlery  "  was  equally  a  refuge  for  the 
stranger  and  the  wayfarer  so  long  as  he  paid  for  his  entertainment.  But 
the  home  of  the  few  has  been  invaded  by  the  sanitarian,  and  the  temporary 
abode  of  the  many  cannot  claim  immunity.  The  law  reaches  far  to-day. 
Let  us  see  how  far  it  can  influence  a  hotel. 

How  far  the  common  law  is  concerned  with  the  question  can  be  better 
answered  by  a  lawyer,  and  we  present  here  the  views  of  Samuel  H.  Orwig, 
Esq. 

The  Constitution  of  the  United  States  provides  that  the  people  shall  be 
secure  in  their  persons,  houses,  papers,  and  possessions  from  unreasonable 
search  and  seizures. 

The  cases  in  which  the  health  authorities,  either  at  common  law  or  by 
statute,  may  quarantine  private  dwellings,  are  confined  exclusively  to  cases 
of  pestilence  or  contagious  disease.  The  persons  quarantined  are  entitled  to 
the  care  and  protection  necessary  for  their  welfare  and  safety,  and  the  neglect 
to  provide  for  their  necessities  pending  the  quarantine  would  subject  the 
party  guilty  of  gross  neglect  to  action  at  law  either  civil  or  criminal. 

The  legal  rights  of  an  owner  of  a  dwelling  house  when  his  tenant  is 
quarantined  are  necessarily  limited  by  the  facts  and  circumstances  in  each 
case.  The  landlord  is  subject  to  the  like  restraint,  as  are  all  other  persons, 
so  far  as  may  be  necessary  to  protect  the  public  health.  It  is  self-evident  that 
he  would  not  be  permitted  to  break  the  quarantine.  His  legal  rights  to  col- 
lect rents  or  recover  possession  may  be  in  abeyance  and  would  be  restrained 
so  far,  and  so  far  only,  as  the  welfare  of  the  public  generally  and  the  afflicted 
in  quarantine  would  seem  to  require;  and  it  would  be  safe  to  assume  that  the 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  9 

courts  would  excuse  an  excessive  exercise  of  authority  to  quarantine,  in  cases 
where  there  is  great  peril  to  the  public  health. 

It  is  the  nature  of  the  disease  that  warrants  the  quarantine  and  not  the 
character  of  the  place  in  which  the  infected  person  or  persons  may  be.  A 
hospital  for  contagious  diseases  is  in  itself  always  in  quarantine. 

The  proprietor  of  a  hotel  or  lodging  house,  like  the  owner  of  a  dwelling,, 
may  suffer  inconvenience  and  perhaps  loss  by  reason  of  quarantine. 

His  legal  rights  may  be  in  abeyance  for  the  time  being  and  must  be 
measured  finally  by  the  same  general  rules  that  govern  in  the  case  of  a  dwell- 
ing house. 

If  the  removal  of  a  lodger  or  a  guest  at  a  hotel  to  a  hospital  would  secure 
the  public  from  the  danger  of  contagion,  it  would  seem  to  be  the  better  course 
to  pursue  rather  than  to  bar  the  doors  of  a  public  house. 

How  far  the  constituted  authorities  charged  with  the  duty  of  protecting 
the  public  health  have  acted  within  their  limits  in  any  particular  case,  or  may 
have  exceeded  them,  may  be  submitted  to  a  court  of  law  and  then  and  there 
be  determined  in  the  light  of  all  the  facts  and  conditions  in  the  case. 

The  inconvenience  and  loss  necessarily  resulting  from  quarantine  may 
or  may  not  entitle  the  person  or  persons  who  suffer  such  inconvenience  or  loss 
to  redress  at  law.  The  courts  will  not  interfere  with  the  legitimate  use  of  the 
police  power. 

Thus  it  appears  that  the  common  law  gives  pretty  full  latitude  for  the 
regulation  and  sanitation  of  the  class  of  buildings  this  chapter  is  considering- 
We  have  been  to  some  care  to  examine  the  building  regulations  of  several 
cities,  and  find  that  such  structures  as  theaters  and  hospitals  are  very  ade- 
quately provided  for,  while  there  are  in  most  cities  very  inadequate  regula- 
tions as  regards  the  construction  of  hotels.  Unfortunately  hotels  are  apt  to 
be  like  Topsy,  "  jess  grow  up,"  and  be  metamorphosed  from  some  other 
structure  and  have  wings  added  and  appropriate  adjoining  buildings,  until 
the  city  awakes  to  the  fact  that  it  has  a  big  hotel  that  is  a  fire  trap. 

Here  in  my  own  city  we  wished  to  enlarge  a  hospital  by  adding  a  new 
wing,  and  we  were  obliged  to  change  plans  and  spend  several  thousand  dol- 
lars additional  in  order  to  conform  to  city  regulations.  For  instance,  the 
laundry  floor  is  based  upon  such  heavy  iron  girders  that,  were  a  track  laid 
over  it,  it  would  be  safe  to  run  a  loaded  trolley  car  across  it.  But  since  that 
was  built  two  hotels  have  gone  up  that  look  beautiful,  but  are  very  inflammable. 
And  our  building  laws  are  based  upon  those  of  one  of  our  largest  cities.  If  it 
is  necessary  to  make  a  hospital  practically  fireproof  certainly  the  same  need 
exists  for  a  hotel. 

In  the  May,  1909,  issue  of  the  Pacific  Monthly,  the  following  statement 
is  made  about  fires  in  the  United  States: 

Week  after  week  we  average  up  three  theaters,  three  public  hal]s,*twelve  churches,, 
ten  schools,  two  hospitals,  two  asylums,  two  colleges,  six  apartment  houses,  twenty-six 
hotels,  three  department  stores,  two  jails,  one  hundred  and  forty  flat  houses,  and  about 
sixteen  hundred  homes  destroyed  by  fire. 


10  HYGIENE 

Note  the  large  number  of  hotels  and  flat  houses  in  the  list.  Municipali- 
ties have  been  slow  to  exact  proper  building  laws  in  this  country,  and  it  is 
amazing  how  fire  will  swirl  through  block  after  block  of  our  showy  American 
cities.  In  Europe  they  do  these  things  better.  The  buildings  are  not 
erected  there  with  the  idea  of  tearing  them  down  in  a  few  years.  A  little 
further  in  this  chapter  details  of  construction  will  be  given,  but  here  it  is 
proper  to  say  why  so  many  hotels  and  lodging  houses  burn.  Two  main 
sources  of  origin  of  fire  are  the  kitchen  and  the  heating  plant.  The  kitchens 
of  hotels  are  nearly  always  too  small  and  too  many  wooden  closets  are  built 
right  around  the  ranges.  There  is  a  tendency  to  keep  coffee  boilers,  cereal 
steamers,  and  hot  water  boilers  going  all  night,  and  they  are  often  heated  by 
gas  and  the  flames  more  or  less  exposed.  Grease  boiling  over  or  being  spilled 
is  an  added  danger,  and  matches  are  seldom  properly  cared  for  in  hotel 
kitchens. 

Several  states  provide  for  the  inspection  of  hotels  and  lodging  houses, 
but  Illinois  has  one  of  the  fullest  laws,  and  we  will  here  refer  to  some  of  its 
main  features.  Instead  of  having  some  separate  board,  the  state  board  of 
health  is  given  supervision.  The  statute  requires  that  not  less  than  four 
hundred  cubic  feet  of  air  space  be  provided  for  every  occupant  of  the  sleeping 
apartments,  and  the  placing  of  the  beds  and  proper  ventilation  is  defined. 
Records  and  annual  statements  are  required  of  the  proprietors,  and  the  in- 
spectors of  the  board  can  order  and  enforce  necessary  sanitary  rules. 

Florida  has  the  most  stringent  rules.  The  state  board  inspects,  and 
charges  two  dollars  and  issues  a  certificate  of  having  successfully  passed 
inspection.  In  an  uninspected  hotel,  if  a  guest  becomes  ill  from  insanitary 
conditions,  he  can  bring  suit  against  the  hotel  for  damages.  Refusal  of  the 
proprietor  to  abate  insanitary  conditions  may  result  in  fine  or  imprisonment. 

Maine  and  some  other  states  have  regulations  requiring  the  disinfection 
of  a  room  after  its  occupancy  by  a  tuberculous  case. 

The  department  of  health  of  the  city  of  Chicago  has  a  list  of  about  two 
thousand  restaurants  to  inspect,  and  it  finds  difficulty  in  bringing  all  up  to 
standard.  So  many  are  conducted  by  very  poor  people  that  it  is  a  hardship 
to  them  to  provide  proper  facilities. 

By  means  of  subterfuge  or  by  posing  as  a  patron,  the  editor  has  seen 
behind  the  counters  and  into  the  kitchens  of  Chinese,  Italian,  and  other 
foreign  restaurants.  The  worst  ones  I  have  seen  were  run  by  Greeks  and 
Italians,  while  the  Chinese  were  comparativel)^  clean.  It  has  been  an  amaze- 
ment to  me  to  find  in  Philadelphia  and  other  large  cities  basements  and 
cellars  used  by  restaurants  for  the  storage  and  preparation  of  food  in  states 
almost  beyond  description.  Especially  was  I  amazed  to  find  an  awful  state 
of  plumbing  supposedly  "  inspected." 

There  is  an  abuse  in  the  hotel  business  that  needs  attention.  Some 
of  the  courts  are  very  slow  to  give  licenses  for  saloons,  but  are  ready  enough 
to  grant  them  to  hotels.  So  the  man  who  wishes  to  run  a  saloon  opens  a 
"  hotel  "  in  a  little  fifteen  by  thirty  building,  with  hardly  room  enough  to 
house  the  saloon  and  his  family,    and  with  not  the  remotest  idea  of  ever 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  11 

taking  more  than  the  legally  required  number  of  guests.  These  places  rob 
the  bars  of  the  real  hotels  and  make  the  profits  so  small  that  it  is  hard  to 
exact  of  the  hotel  the  facilities  it  should  have.  It  is  surprising  how  many 
hotels  are  just  barely  existing,  and  what  small  profits  are  made  by  many 
large  establishments.  It  is  simple  justice  for  the  courts  to  refuse  to  issue  so 
many  licenses.  If  the  state  sells  a  license,  it  should  protect  the  holder  from 
ruinous  competition.  It  is  the  poor  fellow  who  is  "  down  and  out  "  who  is 
most  liable  to  steal  a  loaf  of  bread,  and  it  is  the  saloon  keeper  who  makes  a 
bare  livingwho  is  most  apt  to  keep  a  dirty  place  and  sell  dirtv  liquor.  Itwould 
largely  advance  the  sanitation  of  hotels  if  the  lower  strata  of  them  were  forced 
out  of  business  by  the  courts  refusing  to  grant  licenses  to  any  but  the  real 
enterprises  conducted  along  right  lines.  It  is  claimed  that  it  is  hard  to  make 
a  financial  success  of  a  hotel  unless  it  has  a  bar.  If  that  be  true,  it  is  surely 
the  duty  of  the  courts  to  distribute  licenses  in  such  a  way  that  the  public 
would  be  served  in  a  cleanly  and  well-ordered  manner,  and  that  can  be  done 
only  by  a  paying  business. 

It  is  well  to  remember  that  the  hotels  have  first  contact  with  the  great 
world  outside,  and  they  can  bring  epidemic  to  us  or  we  can  go  to  summer 
hotels  ourselves  and  bring  home  typhoid  fever.  It  is  a  matter  of  great  public 
importance  to  keep  our  hotels  up  to  a  high  standard  of  excellence.  All 
communities  should  have  hotels  of  which  they  can  be  proud,  and  they  should 
do  all  they  can  to  promote  the  tone  and  the  legitimate  business  of  these 
places;  then  we  shall  have  sanitary  hotels. 

A  physician  in  general  practice  learns  something  of  the  woes  of  the 
hotel  keeper.  It  seems  that  a  large  portion  of  the  public  regard  a  hotel  as  a 
place  where  they  have  an  especial  dispensation  to  do  as  they  please.  Intem- 
perance and  various  indiscretions  are  more  the  fault  of  the  guests  than  of  the 
proprietor,  nine  times  out  often.  It  is  very  hard  to  secure  and  to  retain  good 
hotel  help,  and  many  of  the  irregularities  and  insanitary  conditions  found  in 
hotels  are  due  to  careless  and  incompetent  help.  As  to  the  food  served,  that 
is  discussed  in  the  chapter  upon  pure  food  and  drugs. 

Lodging  houses  are  more  apt  to  become  insanitary  than  are  hotels,  and 
the  conditions  found  in  the  lodging  houses  where  foreign  laborers  are  housed 
is  often  frightful  and  is  contrary  to  good  health  and  good  morals.  The  worst 
conditions  of  that  character  that  have  come  to  my  attention  exist  in  the  small 
places  employing  foreign  labor  in  the  mining  and  steel  works.  One  cannot 
hold  the  authorities  too  much  to  blame  for  these  conditions,  since  an  inspec- 
tion and  cleaning  up  improves  the  state  of  affairs  for  about  a  week,  and  then 
they  gravitate  back  to  the  old  ways.  These  foreigners  want  to  send  all  the 
money  possible  back  to  the  "  old  country,"  and  they  seem  content  to  live  like 
swine  here  in  order  to  get  a  little  saved  to  live  upon  in  Europe  after  their 
return.  Unfortunately,  many  of  these  foreign  lodging  houses  are  situated 
just  beyond  the  line  of  the  municipality,  and  the  building  and  sanitary  regu- 
lations do  not  reach  them. 

My  suggestions  would  be:  first,  adopt  the  plan  being  tried  in  the  South, 
of  enacting  a  state  law  extending  the  authority  of  all  municipal  health  boards 


12  HYGIENE 

and  officers  for  one  mile  beyond  the  corporate  limits;  second,  place  a  placard 
upon  the  door  of  every  room  occupied  as  sleeping  quarters,  stating  how  many 
persons  are  permitted  to  occupy  the  apartment,  and  fining  the  proprietor  for 
allowing  an  excess  number  to  occupy  said  rooms;  third,  extend  the  municipal 
garbage  regulations  to  cover  these  places  and  charge  a  small  sum  for  the 
service;  fourth,  in  case  of  over  twenty  unmarried  adult  occupants  in  one  house 
there  should  be  a  janitor  provided,  and  he  should  be  acceptable  to  the  sanitary 
authorities,  and  be  required  to  report  to  them;  fifth,  storage  of  rags,  paper, 
junk,  or  any  other  material  apt  to  be  insanitary  should  be  prohibited  in  these 
buildings;  sixth,  allow  no  licenses  for  the  sale  of  intoxicants  within  these 
buildings  and  grant  no  "  club  "  licenses  therein. 

In  addition  to  these  suggestions,  as  so  many  of  these  people  are  mem- 
bers of  the  Roman  Catholic  Church,  much  can  be  accomplished  by  the  sani- 
tary authorities  asking  for  the  co-operation  of  the  Church  in  the  districts 
involved.  The  bishops  and  priests  of  many  cities  have  given  substantial  aid 
in  furtherance  of  such  plans. 

Lodging  houses  for  working  girls  are  very  often  conducted  in  a  very 
careless  manner.  The  Young  Women's  Christian  Associations  are  pro- 
viding quarters  for  many  girls,  but  they  cannot  reach  all.  Their  work  might 
well  be  extended  to  include  a  co-operation  with  the  sanitary  authorities  and 
the  anti-vice  leagues  in  providing  safe  and  sanitary  lodging  for  the  army  of 
young  women  employed  in  stores  and  factories  and  separated  from  all  home 
influences.  Places  like  Mills's  Hotels  for  men  are  needed  for  women.  The 
wages  of  most  of  the  women  workers  should  be  placed  upon  a  more  equitable 
basis,  and  then  their  living  quarters  would  soon  be  improved  by  themselves. 

Quarantine  in  hotels  and  public  buildings. — What  Mr.  Orwig  has  stated 
in  this  chapter  nearly  covers  the  subject.  Doubtless  a  hotel  can  be  fully 
quarantined,  and  such  measures  have  been  placed  in  force  when  smallpox  or 
scarlet  fever  was  present  and  the  hotel  building  a  small  one.  However,  the 
regulations  of  the  District  of  Columbia  are  safe  guides  in  sanitation  gen- 
erally.    The  following  is  quoted  from  the  last  edition: 

If  such  premises  be  a  hospital,  asylum,  hotel,  or  apartment  house  said  placards 
or  warning  signs  may,  in  the  discretion  of  said  health  officer,  be  placed  in  a  conspicuous 
position  or  positions  within  said  premises,  at  such  place  or  places  as  said  heahh  officer 
may  determine.    .    .    . 

That  whenever  any  person  in  said  District  is  an  inmate  of  any  premises  occupied 
by  three  or  more  families,  or  of  any  tenement  house,  hotel,  or  apartment  house,  and 
is  suffering  from  any  contagious  disease,  and  cannot,  in  the  opinion  of  said  health 
officer,  be  properly  isolated  in  such  premises,  tenement  house,  lodging  house,  hotel, 
or  apartment  house,  said  person  shall  be  removed  as  expeditiously  as  possible,  under 
direction  of  said  health  officer,  to  the  public  hospital  or  to  such  other  place,  satisfactory 
to  said  officer,  provided  by  and  at  the  expense  of  said  person,  his  parents  or  guardians; 
if  such  person  cannot,  in  the  opinion  of  said  health  officer,  be  removed  as  aforesaid 
without  endangering  his  life,  said  health  officer  may  cause  such  persons  in  the  vicinity 
to  be  removed  as  are  in  danger  of  contracting  the  disease.  Any  person  suffering  from 
any  contagious  disease,  and  requiring  to  be  treated  at  public  expense,  may,  at  the 
discretion  of  said  health  officer,  be  removed  to  the  public  hospital  for  treatment. 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  13 

All  hospitals  and  dispensaries  in  the  District  of  Columbia  are  required 
to  provide  isolation  wards  or  rooms.  The  public  are  not  so  fortunate  in  most 
places.  In  my  city  we  have  a  "  Sanitary  Hospital,"  and  it  is  opened  only 
when  smallpox  or  a  serious  epidemic  of  some  other  communicable  disease 
occurs.  Recently  we  had  leprosy  there.  Such  a  hospital  is  not  expensive 
to  build  and  the  cost  of  maintenance  is  not  very  great.  State  boards  can 
demand  of  a  community  that  they  provide  quarters  for  smallpox  and  other 
cases,  and  it  is  a  serious  emergency  for  a  city  or  county  to  face  these  demands 
when  they  have  made  no  provision  for  housing  such  cases.  Our  building  is 
comfortable  and  good  nursing  and  medical  attendance  is  supplied,  but  the 
public  seem  to  fear  "  the  smallpox  hospital  "  as,  here,  all  cases  must  go  there 
and  no  provision  is  made  for  classifying  the  cases  socially  or  providing  espe- 
cial accommodations.  Cities  following  the  plan  we  have  adopted  could  well 
allow  the  well-to-do  patient  to  provide  private  pay  supervision,  as  in  the 
District  of  Columbia. 

Hotels,  hospitals,  and  public  buildings,  inclusive  of  apartment 
houses,  are  put  to  manifest  loss  and  inconvenience  when  the  municipality 
provides  no  place  to  which  cases  of  communicable  disease  can  be  removed, 
and  it  impresses  me  that  all  places  populous  enough  to  have  large  hotel 
interests  should  make  adequate  provision  in  the  way  indicated.  See  the  arti- 
cle upon  Seaside  Resorts,  in  Chapter  VI. 

"  Homes,"  asylums,  and  charitable  institutions  should  provide  an  isola- 
tion ward  or  rooms,  especially  if  children  are  housed  in  the  building.  Board- 
ing schools  and  colleges  would  save  themselves  great  inconvenience  and  pos- 
sibly large  losses,  by  having  such  an  isolation  ward  or  cottage.  And  yet  this 
matter  is  much  neglected,  even  at  quarantine  stations.  Philadelphia  re- 
cently docked  a  vessel  filled  with  steerage  passengers  who  had  been  exposed  to 
smallpox  on  board,  and  yet  the  city  and  even  the  federal  authorities  there  had 
no  place  large  enough  to  detain  so  large  a  body  of  people. 

General  hospitals  frequently  have  cases  of  communicable  disease  de- 
velop therein,  and  there  is  a  flurry  at  once  as  to  what  to  do.  Most  general 
hospitals  are  not  prepared  for  such  contingencies.  From  what  observation 
I  have  been  able  to  make,  it  impresses  me  as  best  to  erect  a  separate  building 
for  such  isolation.  I  was  visiting  a  hospital  where  a  case  of  bubonic  plague 
was  brought  in.  Fortunately,  it  had  an  isolation  building,  and  no  excitement 
occurred  either  among  the  patients  or  in  the  community.  Unfortunately  for 
us,  Harrisburg  hospitals  do  not  have  sufficiently  large  grounds  to  erect  such 
buildings.  The  annexed  letter  will  show  what  we  have  to  do  when  cases 
develop  in  the  wards. 

Harrisburg  Hospital 

Harrisburg,  Pa.,  March  9,  1909. 
Thomas  S.  Blair,  M.D., 

Dear  Sir:  As?  you  know,  epidemics  of  scarlet  fever  and  measles  are  running 
their  courses  in  the  Harrisburg  Hospital.  Subject  to  the  approval  of  the  State  Depart- 
ment of  Health,  the  second  and  third  floors  of  the  new  Ward  and  Dispensary  Building 
have  been  placed  under  quarantine.  Patients  who  have  been  stricken  with  ihe  diseases 
and  patients  who  have  been  exposed  are  in  the  quarantined  wards. 


14  HYGIENE 

For  the  present  the  old  male  medical  ward  will  be  used  for  new  female  patients, 
and  the  old  surgical  ward  for  new  m.ale  patients.  The  private  rooms  are  also  available. 
Please  do  not  admit  any  except  accident  cases  or  cases  which  require  immediate 
attention  and  cannot  be  cared  for  at  home.  Please  assure  any  paiients  who  can  wait 
that  we  will  admit  them  as  soon  as  our  quarantine  shall  be  raised.  We  have  taken 
vigorous  measures,  and  we  hope  to  be  successful  in  stamping  out  the  diseases  promptly. 

Please  discharge  any  patients  under  your  care  who  can  be  cared  for  at  home. 
The  conditions  imposed  by  the  health  department  are  as  follows:  private  room 
patients  may  be  discharged  after  antiseptic  baths  and  after  their  clothes  have  been 
disinfected;  ward  patients  may  be  discharged  if  they  are  immune  from  either  of  the 
diseases  to  which  they  have  been  exposed  by  reason  of  having  had  a  previous  attack 
of  the  disease.  Some  patients  have  been  exposed  to  both  diseases.  These  cannot  be 
discharged  unless  they  have  had  both  scarlet  fever  and  measles.  We  will  depend 
on  you  to  discharge  any  patients  you  may  have,  if  they  can  possibly  be  cared  for  at 
home,  and  can  stand  being  moved.  We  wish  to  have  as  much  room  as  possible  for 
new  patients. 

Yours  very  sincerely, 

Henry  B.  McCormick, 
President  Board  of  Aianagers,  Harrishurg  Hospital 

In  the  event  of  a  case  of  smallpox  or  other  dangerous  communicable 
disease  being  discovered  in  a  public  building,  closing  the  building  during 
fumigation  is  necessary  and  the  fumigation  should  be  thorough.  In  this 
city,  churches,  schools,  the  mayor's  office  and  the  state  library  have  all  been 
closed  for  fumigation  when  any  public  danger  was  apprehended.  Physi- 
cians' offices  should  come  under  the  same  category.  The  chapter  upon  dis- 
infection gives  full  directions  for  disinfection  of  small  houses. 

Flats  and  apartment  houses. —  Much  that  has  been  said  applies  to  this 
subdivision.  In  Paris  and  other  European  cities  the  question  of  the  sanita- 
tion of  apartments  has  been  well  worked  out.  The  concierge  and  the  gen- 
darmes are  different  quantities  altogether  from  the  American  janitor  and 
police.  In  France  and  Germany  one  expects  to  have  his  home  supervised, 
but  the  American  resents  that  sort  of  thing.  Much  can  be  done  by  having 
stringent  building  laws  regulating  the  erection  of  flat,  apartment,  and  tene- 
ment houses.  Some  of  these  buildings  are  so  sumptuous  that  every  possible 
sanitary  advantage  is  supplied  as  a  matter  of  course.  Good  tenements  or 
"  model  tenements,"  as  some  merely  good  tenements  are  called,  usually  house 
a  desirable  class  of  people,  and  there  is  very  little  trouble  as  regards  their 
sanitation.  Ordinary  prudence  should  demand  that  the  owners  of  these 
buildings  provide  an  isolation  room  or  rooms.  When  an  apartment  house  is 
provided  with  safe  facilities  for  the  isolated  care  of  communicable  disease,  the 
occupants  do  not  become  alarmed  and  vacate  the  premises.  The  nurse  or 
caretaker  of  the  patient  should  live  in  the  isolation  quarters.  When  the  house 
is  of  the  character  that  will  attract  tenants  capable  of  paying  a  trained  nurse, 
this  plan  works  out  very  well,  but  with  people  apt  to  nurse  the  members  of 
their  families,  it  does  not  do  so  well. 

Ordinary  tenements  so  frequently  are  found  in  the  slums  that  their  sani- 
tation would  naturally  come  under  the  chapter  upon  slums  and  town  nuisances 


PARKING   CONCEALING   A  THREE  THOUSAND  TON    COAL   PIT    (behind    bov) 

IDEAL  APARTMENT  HOUSES.     Light,  air,  and  a  park  for  a  front  yard 

A    STREET    OF    APARTMENT    HOUSES,    NEW    YORK    CITY 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  IS 

(q.  v.).  I  am  almost  tempted  to  call  the  sanitation  of  this  class  of  building 
"  the  attempted  sanitation,"  but  presume  there  are  in  existence  "  tenement 
houses  "  that  are  sanitary.  I  have  never  been  so  fortunate  as  to  have  seen 
one.  Perhaps  I  may  some  day,  but  doubt  very  much  if  it  is  possible  to  house 
a  large  number  of  ignorant  people  under  one  roof  and  keep  the  place  as  it 
should  be  kept,  unless  it  be  a  jail,  a  hospital,  or  an  institution  conducted  by 
intelligent  people.  Even  then,  it  is  hard  enough.  I  have  interested  myself 
somewhat  in  religious  and  charitable  w^ork  among  the  class  of  people  who 
herd  together.  Herding  together  is  a  different  thing  from  living  together. 
Ignorant  and  careless  people  always  herd.  They  always  have  done  so  and  I 
presume  they  ever  will.  It  takes  a  considerable  degree  of  education  and 
some  considerable  amount  of  sanitary  and  ethical  sense  as  well  for  a  large 
body  of  people  to  live  together.  Witness  the  army  camps  of  all  history,  the 
religious  communities  of  the  middle  ages,  the  puebloes  and  Aztec  village 
buildings  of  the  Southwest,  and  the  various  trials  at  digging  canals. 

In  this  day,  when  we  recognize  the  causes  of  tuberculosis  and  typhoid, 
it  seems  but  one  step  further  to  realize  that  the  "  tenement  house  "  of  the  past 
must  go.  It  does  not  belong  to  the  twentieth  century,  and  cannot  be  made  to 
fit  in  with  the  general  scheme  of  things  as  advocated  to-day.  So  long  as 
people  are  kept  in  reeking  wrecks  and  rotten  rows,  neither  religion  nor  charity 
is  able  to  reach  any  large  number  of  them.  As  a  nation  we  have  no 
right  to  keep  human  beings  in  quarters  not  fit  for  cattle.  AH  municipalities 
should  absolutely  condemn  such  shacks  as  one  sees  in  the  slums.  If  they 
have  not  laws  to  do  so  they  should  promptly  get  them. 

Summer  and  resort  hotels. —  Under  the  last  heading,  "  Rural  Resorts," 
in  Chapter  VIII,  the  work  being  done  by  the  New  York  board  is  described. 
While  the  final  revision  of  this  chapter  was  in  progress,  a  later  report  came 
to  hand  showing  that  the  work  of  the  board  has  already  been  effective  in 
many  places.  It  is  largely  ignorance  and  thoughtlessness  that  is  responsible 
for  insanitary  hotels  and  resorts.     However,  it  is  not  all  to  be  covered  so 

charitably.     If  one  goes  out  in  a  rowboat  on  Lake ,  so  the  report  states, 

and  looks  out  for  the  intakes  and  sewer  outlets,  he  will  want  to  filter  the  water 

he  drinks  there.     There  are  places  in  the  ( )  Islands  no  better.     The  ice 

supply  of  some  of  these  hotels  is  of  a  dubious  character,  being  privately  cut 
from  places  not  inspected  at  all.  All  of  the  state  boards  should  issue  a  cir- 
cular of  information  for  hotels. 

The  privileges  that  may  he  safely  allowed.- —  The  legal  phases  of  this  ques- 
tion have  been  discussed,  but  there  are  some  medical  ones  that  should  have 
separate  consideration.  Probably  a  perfect  quarantine  has  never  existed. 
Little  leaks  will  occur.  When  it  comes  to  a  partial  quarantine  of  a  building, 
these  little  leaks  are  apt  to  be  numerous.  As  regards  hotels,  it  is  by  far  the 
safest  plan  to  remove  an  infectious  case  from  the  building.  If  the  case  is 
isolated  and  treated  in  the  building,  every  effort  should  be  made  to  secure  a 
trained  nurse,  even  if  the  proprietor  has  to  board  her  free.  From  the  business 
point  of  view,  if  from  no  other,  it  will  pay.  It  would  be  well  to  cut  out  the 
annunciator  from  the  infected  rooms  because  the  servants  like  to  get  extra 


16  HYGIENE 

fees  and  are  very  liable  to  connive  with  the  patient  or  his  indiscreet  friends 
and  various  articles  are  spirited  into  and  out  of  the  rooms.  Needless  to  say, 
they  are  not  disinfected.  The  bar  should  be  instructed  to  send  nothing  to 
the  rooms  without  orders  from  the  physician.  The  chambermaid  is  another 
loose  cog  in  the  mechanism,  and  she  is  apt  to  do  even  more  harm  than  the 
"  bell  hop,"  because  she  is  apt  to  be  longer  in  the  rooms  and  become  con- 
taminated with  dust,  and  she  is  more  liable  to  handle  clothing.  The  hotel 
laundry  should  not  mingle  the  linen  from  these  rooms  with  any  other.  Chil- 
dren in  the  building  are  apt  to  stray  in,  as  is  also  tabby  and  the  poodle,  and 
they  must  all  be  watched.  No  one  but  the  doctor  should  determine  what 
things  may  be  safely  done.  Conditions  vary  and  the  list  of  safe  things  varies 
in  every  concrete  case.    In  general,  hotels  are  a  poor  place  to  practice  isolation. 

Apartment  houses  are  a  little  safer,  since  the  individual  apartment  is 
more  like  an  individual  home.  Architects,  in  planning  the  better  class  of 
homes,  nearly  always  make  provision  for  an  especially  constructed  suite  of 
rooms  for  the  reception  of  ill  persons.  Such  rooms  should  be  found  in  apart- 
ment houses,  but  even  if  they  are  not  found,  it  is  a  comparatively  easy  matter 
to  isolate  a  flat  or  suite  of  apartments.  If  there  is  not  a  private  bath,  great 
care  must  be  exercised.  Also  cold-storage  apartments  for  the  use  of  several 
tenants  should  not  be  used  to  store  anything  that  has  been  in  the  sickroom. 
The  trunk  room  is  a  source  of  danger,  and  the  physician  should  lay  down 
stringent  rules  concerning  the  matter.  There  is  often  a  pharmacy  in  the 
building  and  the  patient  sends  there  for  ices  and  soda.  Glasses  and  all  uten- 
sils should  be  sterilized  before  returning  them.  Apartment  houses  with  a 
common  dining  hall  often  send  bottled  milk  to  the  sickroom.  Such  bottles 
should  be  sterilized  before  returning.  Newspapers  and  magazines  entering 
the  rooms  must  not  be  loaned,  but  should  be  burned  after  reading.  Send 
the  cat  or  dog  away  and  keep  them  away.  Sending  out  suits  to  be  pressed, 
sending  out  letters  with  children  in  the  building,  hanging  blankets  and 
clothing  on  a  balcony  where  children  play,  sending  down  soiled  clothing  and 
dishes  in  the  dumb  waiter  or  elevator,  sending  waste  paper  and  cigar  stubs 
from  the  patient  to  the  cellar  to  be  burned  when  the  janitor  gets  ready,  these, 
and  many  other  little  matters  should  be  watched. 

Cases  in  "  tenement  houses  "  spread  unless  the  city  sends  a  responsible 
party  there  with  power  to  act.  I  never  knew  quarantine  without  a  guard  to 
amount  to  anything  in  a  tenement.  Perhaps  others  have  had  a  more  fortu- 
nate experience.  I  always  try  to  keep  my  eyes  open,  and  yet  I  have  been  in 
the  room  with  smallpox  cases,  in  a  dark  tenement,  and  did  not  know  until 
afterwards  that  they  were  there.  Allow  no  privileges  at  all  in  a  tenement. 
The  only  safe  way  is  to  put  the  job  right  up  to  the  authorities. 

Transients  and  vital  statistics. —  I  have  reported  tuberculous  cases  that 
have  remained  in  this  city  for  a  few  days  and  then  removed  to  some  other  place 
where  it  is  likely  they  were  also  reported.  Or,  I  may  report  a  case,  and  it 
soon  turns  up  at  the  tuberculosis  dispensary  or  a  hospital.  This  shows  the 
necessity  of  giving  the  full  name  and  address  in  all  reports.  With  some 
physicians  a  large  portion  of  their  cases    are    transients.     At  my  clinic  I 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  17 

report  foreigners  with  unpronounceable  names,  and  few  of  them  stay  here  for 
a  year.  Many  of  them  are  doubtless  reported  from  the  next  stopping  place. 
I  would  suggest  that  all  reports  of  chronic  communicable  disease  state  whether 
or  not  they  are  transient  residents.  In  the  general  hospital  here  we  treat 
many  cases  of  typhoid  that  do  not  originate  here.  It  is  hardly  fair  to  the 
city  records  for  these  cases  to  appear  therein.  Transients  in  hotels  and 
lodging  houses  come  under  the  same  category. 

An  Example  of  a  Sanitary  Hotel 

It  is  rather  difficult  to  convey  concrete  teachings  without  a  specific 
example,  and  this  applies  to  sanitation  with  greater  force  than  to  most  other 
subjects.  There  are  so  many  sanitary  hotels  in  this  country  that  I  found 
some  difficulty  in  selecting  one  that  appeared  to  me  could  be  ethically  used 
for  our  present  purpose.  Within  the  last  few  years  several  very  modern  and 
thoroughly  sanitary  hotels  have  been  bidding  for  the  patronage  of  wealthy 
people,  and  what  I  can  see  about  them  appears  ideal,  except  that  they  have 
not  been  in  operation  long  enough  to  have  worked  out  fully  a  few  problems 
older  and  probably  more  old-fashioned  institutions  have  solved.  It  takes 
a  steady  and  well-paying  patronage  to  provide  some  things  discriminating 
people  now  demand.  Sanitary  appliances  are  well  in  their  way,  but  sanitary 
administration  is  better.  Usually  the  place  having  call  for  the  latter  will 
install  the  former. 

Wishing  to  avoid  any  appearance  of  commercialism  I  have  selected  as 
an  instance  of  sanitary  hotel  administration  a  hotel  known  to  every  one,  and 
so  much  a  part  of  the  public  life  of  New  York  city  to  remove  any  suspicion 
of  any  effort  upon  its  part  to  secure  free  advertising  or  any  commercialism  or 
favoritism  upon  my  part. 

The  management  of  the  Waldorf-Astoria  has  kindly  supplied  the  fol- 
lowing data,  and  in  presenting  it  I  wish  it  understood  that  the  description 
will  fit,  in  essentials,  many  other  good  hotels.  On  the  other  hand,  I  know 
many  expensive  hotels  that  need  to  copy  the  example  I  give,  and  it  is  to  be 
hoped  that  the  instance  will  prompt  physicians  who  read  this  to  demand 
sanitation  in  all  hotels. 

Plumbing. —  The  Waldorf-Astoria  has  upwards  of  one  thousand  bathrooms, 
which  of  necessity  require  a  great  deal  of  attention  in  the  way  of  maintaining  cleanli- 
ness, and  keeping  the  marble  slabs,  base,  and  tiling,  as  well  as  the  bathtubs  themselves, 
and  the  nickel  trimming  polished.  The  expense  of  this  is  considerable,  the  plumbing 
feature  costing  about  ;^20,000  or  more  per  annum.  All  of  the  fixtures  are  of  course 
thoroughly  disinfected  and  the  sewerage  promptly  disposed  of.  The  hot  water  supply 
is  ample  at  all  hours  of  the  day  and  night.  All  of  the  fixtures  are  "  open  work,"  thus 
insuring  perfect  cleanliness  and  freedom  from  the  slightest  accumulation  of  filth.  In 
addition  to  the  constant  attention  given  the  bathrooms  by  the  help,  they  are  regularly 
inspected  by  the  floor  authorities  and  the  mechanical  force. 

PTater  Supply. —  All  water  supply  used  in  the  hotel  is  carefully  filtered.  The 
consumption  is  about  sixty-eight  thousand  cubic  feet  per  day. 

rent  1 1  at  I  on. —  There  are  in  operation  eighty-three  motors,  which  distribute  pure 
air  to  the  different  parts  of  the  hotel.     The  motors  vary  in  size  from  5  H.P.  to  125  H.P. 


18  HYGIENE 

The  intake  air  is  brought  from  the  top  of  the  building  and  the  exhaust  is  exhausted 
also  at  the  top  of  the  building.  All  intake  air  is  screened  and  cooled  by  means  of 
water  while  in  transmission  through  the  building,  until  it  reaches  its  final  destination. 

Heating. —  The  consumption  of  coal  is  about  seventy  tons  per  day. 

Ice  plant. —  The  hotel  manufactures  and  uses  for  ordinary  purposes  twenty  tons 
of  ice  per  day.  In  addition  to  this  quantitj-  the  cold  storage  departments  throughout 
the  hotel  consume  about  twenty-five  tons  additional,  which  is  also  manufactured  in 
the  hotel.     The  restaurants  use  between  twelve  and  thirteen  hundred  carafes  per  day. 

Electricity  and  elevators. —  The  hotel  generates  all  of  the  electric  current  required 
therein  for  a  total  number  of  thirty-eight  thousand  incandescent  lamps,  the  electric 
grill  in  use  in  the  South  Cafe,  and  the  special  electrical  appliances  throughout  the 
hotel.  There  are  thirty-three  elevators,  of  which  about  half  the  number  are  electric, 
the  balance  being  hydraulic. 

Laundry. —  The  laundry  turns  out  an  average  of  seventy-five  thousand  pieces 
a  day. 

Silver. —  The  silver  department  connected  with  the  hotel  repairs  and  replates 
an  average  of  two  hundred  and  fifty  pieces  per  day,  at  a  total  cost  of  about  $25,000 
per  annum. 

Fire  pumps. —  There  are  four  fire  pumps  with  a  combined  capacity  of  3,433 
gallons  per  minute,  or  4,943,520  gallons  per  day.  There  are  in  addition  between 
six  and  seven  thousand  fire  appliances  throughout  the  hotel. 

Cleaning. —  This  is  largely  done  by  pneumatic  processes,  while  hangings  and 
mattresses  are  sunned  when  of  a  character  not  injured  thereby.  Antiseptics  are  freely 
used  in  the  routine  cleaning  of  certain  portions  of  the  buildings  and  contents. 

Garbage  disposal. —  The  garbage  is  kept  in  a  room  isolated  from  all  food  depart- 
ments of  the  hotel,  and  is  removed  every  night.  The  removal  is  by  private  contract. 
The  room  in  question  is  equipped  with  brine  pipes,  and  the  garbage  is  frozen  in  order 
to  prevent  decomposition.     This  garbage  room  is  never  used  for  any  other  purpose. 

Cooking. —  All  cooking  is  done  in  the  basement  and  odors  disposed  of  by  means 
of  air  ducts  supplied  with  exhaust  fans  which  convey  the  air  to  the  roof  of  the  building. 
The  kitchen  is  also  supplied  with  fresh-air  inlet  ducts,  equipped  with  supply  fans. 
The  kitchen  floors  are  of  marble  and  cement,  and  are  scrubbed  after  each  meal.  Ample 
toilet  and  washroom  facilities  are  provided  for  the  kitchen  help.  No  tuberculous  help 
is  employed. 

Food  and  drink. —  Quality  is  the  very  best  that  can  be  procured  regardless  of 
cost.  Various  refrigerators  at  different  temperatures  for  meats,  butter,  and  eggs, 
fruit,  vegetables,  wines,  liquors,  etc.,  are  cooled  by  private  ice  plant. 

Milk  in  cans  is  kept  standing  in  iced-water  tanks  in  a  room  used  only  for  that 
purpose.  Milk  is  bottled  on  the  premises  in  another  room  which  has  been  approved 
by  the  board  of  health  of  New  York  city.  The  entire  milk  supply  is  in  charge  of  one 
man  and  is  not  accessible  to  any  other  employee.  Certified  milk  in  bottles  is  at  all 
times  available,  and  any  particular  brand  or  mark  is  supplied  upon  request.  Ice 
cream  is  made  on  the  premises  with  the  most  modern  equipment  in  a  perfectly  sani- 
tary space  with  fresh  outside  air.  All  machines,  cans,  etc.,  are  kept  clean  by  a  man 
employed  for  that  purpose.  Material  used  is  the  best,  and  all  cream  is  sterilized. 
All  wines,  liquors,  groceries,  and  other  goods  bought  in  original  packages  are  required 
to  conform  with  the  pure  food  law.  Oysters  are  purchased  only  from  firms  whose 
beds  have  been  inspected  and  licensed  by  the  board  of  health  of  New  York  city. 
"  Inspected  meat  "  is  used,  with  the  following  exceptions.  Baby  lamb,  suckling 
pigs,  milk-fed  poultry,  prize  mutton,  and  such  specialties  are  sometimes  procured 


surgeon's    room,    WALDORF-ASTORIA    HOTEL 
ELEVATOR   ENTRANCE  TO   REST  ROOM  FOR  GUESTS  WHO  ARE  ILL 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  19 

from  the  private  country  estate  of  the  proprietor  and  from  some  of  the  prominent 
"  show  farms  "  in  the  vicinity  of  the  city. 

Inspection. —  The  hotel  is  inspected  hourly  from  basement  to  roof  night  and  day. 
There  are  five  Nevp  York  city  special  officers  in  civilian  dress  in  the  service  of  the  hotel, 
and  betvi^een  the  hours  of  6  a.m.  and  1  a.m.  two  of  these  men  are  on  duty  on  the  main 
floor  in  each  watch,  four  in  all.  The  fifth  man  is  assigned  to  see  that  order  is  pre- 
served on  the  upper  floors.  These  five  men  have  exactly  the  powers  and  authority 
vested  in  the  regular  police  officers  of  the  city  of  New  York,  and  under  agreement  of 
employment  with  each  of  the  help  have  the  right  to  enter  the  rooms  of  employees  at 
any  time. 

In  addition  to  these  special  officers  there  are  eight  night  watchmen  who  report 
for  duty  at  7  o'clock  p.m.  These  men  are  stationed  on  the  diff'erent  floors  and  keep  a 
continuous  watch  throughout  the  night,  reporting  every  hour  to  the  main  office,  where 
their  reports  are  recorded  in  a  book  kept  for  that  purpose,  and  which  is  signed  by  them. 
Their  duty  ends  at  6  o'clock  a.m.,  at  which  time  the  day  force  reports  for  duty  and 
takes  charge  for  the  day.  The  city  assigns  a  number  of  uniformed  police  officers  around 
the  building  whose  duty  it  is  to  keep  the  sidewalks  clear.  In  addition  a  mounted  officer 
is  stationed  at  the  corner  of  Fifth  Avenue  and  Thirty-third  Street,  and  another  at  the 
corner  of  Fifth  Avenue  and  Thirty-fourth  Street.  When  special  events  take  place 
in  the  hotel  the  city  assigns  extra  officers  because  of  the  large  number  of  people  who 
attend  these  functions. 

Infection. —  In  cases  of  infectious  diseases  occurring  in  a  hotel  the  law  provides 
that  the  board  of  health  be  notified,  and  every  means  must  be  taken  to  isolate  the 
patient.  After  the  patient  has  recovered,  the  health  officers  take  charge  of  fumigating 
and  disinfecting  the  rooms  and  furnishings. 

Sanitary  rules  and  employees. —  The  cooks  are  provided  with  clean  white  aprons 
and  jackets  every  day,  the  kitchen  girls  with  white  aprons  twice  a  day,  AH  other 
kitchen  help  are  required  to  present  themselves  for  duty  every  day  with  clean,  washable 
jackets  and  trousers.  Ample  washroom  facilities  are  provided,  and  uncleanliness  of 
person  or  habits  is  not  tolerated.  Waiters  are  required  to  be  clean  shaven,  to  have 
their  hair  neatly  combed  and  their  hands  and  finger  nails  must  be  clean.  They  are 
inspected  by  the  captains  before  being  allowed  to  go  on  duty. 

Medical  aid. —  The  medical  department  is  in  charge  of  a  prominent  physician 
who  has  a  number  of  competent  assistants,  one  or  more  of  whom  is  immediately 
available  at  all  hours  of  the  day  or  night.  A  fully  equipped  surgeon's  room  is  main- 
tained on  the  premises,  where  emergency  cases  can  be  attended  to  and  ordinary  opera- 
tions performed.  This  room  is  used  by  the  medical  staff"  every  day  from  11  to  12 
o'clock  noon,  for  the  purpose  of  giving  medical  aid  to  any  of  the  hotel  employees  who 
require  same.  A  system  of  health  reports  is  kept  in  the  assistant  manager's  office, 
supplied  by  the  clerks  in  charge  of  each  floor,  who  report  daily  the  cases  of  illness,  the 
name  of  the  doctor  in  charge,  nurse,  if  any,  and  the  condition  of  the  patient.  All 
ailing  guests  are  visited  daily  by  a  representative  of  the  management  to  see  that  nothing 
is  left  undone  to  add  to  their  comfort. 

Tobacco. —  No  smoking  is  allowed  among  employees  while  on  duty. 

Animals. —  Dogs  are  the  only  animals  which  the  hotel  is  called  upon  to  care  for, 
and  for  these  a  kennel  is  provided  in  the  basement,  where  every  sanitary  precaution 
is  taken,  and  a  competent  man  employed  to  care  for  the  same.  They  are  fed  at  regular 
intervals  and  in  accordance  with  their  general  disposition  and  breed. 


20  HYGIENE 

Automohiles. —  All  automobiles  belonging  to  guests  are  sent  to  adjacent  garages. 
The  management  also  procures  chauffeurs  for  guests  desiring  same,  and  furnishes 
copies  of  the  municipal  rules  and  regulations  governing  automobiling  to  out  of  town 
guests. 

Rules  for  guests,  as  to  hygiene,  etc.,  about  the  hotel. —  The  hotel  is  extremely 
solicitous  of  the  health  of  its  guests,  and  indefatigable  in  its  attentions  to  those  who 
are  ill.  Cases  of  illness  of  the  guests  are  reported  to  the  manager  promptly,  and 
assistance  promptly  extended,  such  as  hot-water  bottles,  etc.,  kept  on  every  floor. 
A  physician  is  constantly  in  the  house  to  attend  to  any  emergency,  or  the  guest  can 
have  his  own  physician  or  a  specialist  promptly  summoned.  Accidents  are  promptly 
attended  to,  whether  to  guests  or  employees,  the  hotel  maintaining  a  room  fitted  up  as 
a  hospital  operating  room,  with  the  latest  apparatus.  Major  operations  are  occa- 
sionally performed  in  the  patient's  own  room,  the  management  preparing  the  room 
by  removal  of  superfluous  furniture,  curtains,  etc.,  and  surgeons  of  national  reputation 
have  expressed  themselves  as  satisfied  that  the  patient's  surroundings  were  as  satis- 
factory as  at  a  hospital  especially  designed  for  the  purpose;  while  the  room  service  is 
maintained  better  than  in  most  of  the  hospital  private  pavilions,  nurses  being  the  best 
obtainable  from  the  graduates  from  the  best  hospitals.  Special  attention  is  given  to 
the  preparation  of  nourishing  broths  or  dainty  dishes  for  the  sick,  by  the  chef.  Among 
the  great  advantages  to  convalescents  are  the  solariums  on  the  roof  in  winter  and  the 
roof  garden  in  summer. 

Public  Buildings 

Specifications  for  public  buildings. —  The  building  regulations  of  many 
cities  practically  supply  specifications  in  many  particulars.  Michigan  and  a 
few  other  states  have  allowed  their  state  boards  of  health  to  define  sanitary 
specifications  for  state  buildings.  While  what  is  said  in  Chapter  XX  con- 
cerning heating,  lighting,  ventilation,  plumbing,  etc.,  applies  here,  yet  cer- 
tain specifications  particularly  apply  to  large  and  public  buildings.  The  fol- 
lowing is  largely  based  upon  the  Michigan  specifications. 

Heating 

Direct  method  not  suitable  since  an  insufficient  supply  of  fresh  air  is 
obtained  for  rooms  housing  many  persons. 

The  "  direct-indirect  "  method  is  unreliable,  especially  during  high 
winds.     The  indirect  method  is  preferable  to  both  of  the  others. 

The  "  fan  "  method  requires  skilled  help,  but  it  is  recommended  for 
large  assembly  halls,  laboratories,  and  some  factories. 

Automatic  temperature  regulation  is  recommended.  This  is  usually 
accomplished  with  electrical  devices  or  by  bypasses  in  the  heating  or  ven- 
tilating pipes. 

Air  supply  should  be  taken  from  outside  the  building  and  be  conveyed 
to  the  indirect  radiators  through  air-tight  metallic  tubes  made  of  galvanized 
sheet  iron.  The  radiators  should  be  in  rooms  with  cement  floors,  with  well- 
screened  windows  and  tight  doors.  The  rooms  should  be  frequently  cleaned 
and  should  not  be  used  for  storage.  Brick  flues  may  be  used,  but  wooden 
construction  is  not  recommended. 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  21 

Fresh-air  registers  should  not  be  placed  in  the  floors  of  public  buildings 
since  dirt,  sputum,  and  dust  get  into  them.  They  should  be  not  less  than  six 
feet  above  the  floor  and  be  placed  in  the  wall.  It  is  well  to  cover  them  with 
wire  mesh  to  prevent  persons  from  placing  dirt  and  small  objects  in  them. 

Vitiated-air  registers  should  not  be  placed  in  the  floor,  as  the  air  has  to 
make  two  square  turns  in  order  to  escape  to  the  vertical  flues.  They  should 
be  in  the  walls  and  at  the  floor  level.  Summer  ventilation  is  best  accom- 
plished by  open  windows.  If  vitiated-air  registers  are  placed  in  the  ceiling, 
they  interfere  with  the  heating  in  the  winter  time. 

Vertical  ventilating  flues  should  not  be  placed  in  outside  walls,  since 
they  chill  to  such  an  extent  in  cold  weather  as  to  reverse  the  draft.  They 
are  best  placed  in  inside  walls  opposite  windows. 

Ventilating  flues  should  be  suflEiciently  large  to  effect  changes  of  air 
equal  to  thirty-three  and  one  third  cubic  feet  per  minute  for  each  person,  and 
fifty  feet  for  each  person  in  a  hospital  ward.  In  climates  subject  to  great 
change,  or  where  the  difference  between  outside  and  inside  temperature 
exceeds  twenty-five  degrees,  it  is  well  to  place  dampers  in  the  flues,  since  the 
current  is  accelerated  in  cold  weather,  and  the  flues  need  to  be  partly  shut  off. 

The  velocity  of  air  in  flues,  in  feet  per  minute,  due  to  natural  draft,  with  a  difference 
of  twenty-five  degrees  between  the  temperature  of  the  outdoor  air  and  of  that  in  the 
flues. 

Height  of  flue  in  feet  ....    10  20  30  40  50  70  90         125 

Velocity  of  air 171         243         297         342         384         456         516         603 

In  practice  it  is  well  to  allow  a  deduction  of  fifty  per  cent  from  this 
theoretical  data,  to  provide  for  friction,  turns  in  piping,  and  changes  in 
direction. 

Determine  the  usual  number  of  persons  to  occupy  the  room  and  the 
height  of  the  vitiated-air  flue,  then  divide  the  total  amount  of  air  which  must 
be  removed  from  the  room  every  minute  by  the  velocity  shown  for  the  given 
height  of  the  flue.  The  quotient  is  the  necessary  area  of  the  flue  in  square 
feet. 

To  allow  for  space  taken  by  the  grills,  the  face  plates  of  registers  should 
have  one  third  more  area  than  the  vertical  flues. 

Improper  methods  of  disposing  of  vitiated  air  are:  (a)  passing  the 
vitiated  air  to  the  basement  before  it  enters  the  main  ventilating  flue.  To 
make  this  plan  a  success  requires  either  a  fire  or  a  fan  at  the  base  of  the  flue, 
and  this  is  expensive  and  apt  to  be  neglected.  The  use  of  a  fan  is  apt  to  bring 
the  air  from  a  basement,  and  such  air  is  either  dead  or  defiled,  (b)  Con- 
necting the  vitiated-air  flues  of  two  or  more  rooms  together  or  with  a  common 
ventilator  in  the  attic,  makes  it  necessary  to  have  too  many  angles  in  the 
pipes  or  flues,  resulting  in  cross-drafts,  and  the  irregularities  of  weather  con- 
ditions would  interfere  with  the  action  of  some  of  the  flues,  (c)  Discharging 
vitiated  air  into  the  attic  results  in  deranging  the  whole  system  of  ventilation 
during  the  prevalence  of  high  winds,  (d)  Openings  from  several  rooms 
into  a  common  vertical  flue  establishes  cross-currents,  and  when  the  wind  is 
high  the  leeward  side  nearly  always  fails  to  act.     (e)  Connecting  many  flues 


22  HYGIENE 

with  a  main  ventilating  chamber  in  and  running  parallel  to  the  ridge,  without 
a  cross  partition  in  the  ridge  ventilator  between  each  flue,  is  another  plan 
deranged  by  winds,  (f)  If  each  vitiated-air  flue  is  not  extended  through  the 
roof,  a  few  flues  may  be  combined  into  one  stack,  but  it  is  not  well  to  limit 
the  number  of  stacks  on  account  of  conserving  architectural  beauty. 

Conducting  cool  air  from  a  hallway  in  a  public  building  to  be  rewarmed 
results  in  a  deterioration  of  the  air  supply,  and  the  dust  of  a  hallway  (possibly 
infected)  would  be  constantly  agitated  and  would  be  distributed  throughout 
the  entire  building.  When  a  heating  and  ventilation  system  is  made  only 
partial,  and  drafts  up  the  stairs  and  through  transoms  is  depended  upon,  the 
whole  scheme  is  apt  to  be  deranged  and  be  wasteful  in  the  long  run.  (Read 
section  by  Mr.  Snow,  in  Chapter  XX.) 

Sewerage 

Read  the  section  upon  plumbing  in  Chapter  XX.  Public  buildings 
demand  emphasis  upon  certain  features.  Stoneware  pipes  should  not  be 
used  under  buildings.  "  Extra  heavy"  iron  pipes,  with  caulked  lead  joints, 
must  be  used  for  sewers  inside  of  and  for  a  distance  of  a  few  feet  outside 
of  a  public  building. 

It  is  not  advisable  to  connect  tile  subsoil  drains  with  the  sewer,  as  the 
subsoil  is  liable  to  contamination  by  sewage,  and  traps  between  the  subsoil 
drains  and  the  sewer  are  liable  to  become  dry  and  allow  the  sewer  gas  to 
enter  the  building.  Subsoil  drains  should  discharge  into  a  land  drain,  a 
ditch,  a  watercourse,  or  into  a  porous  piece  of  land  at  some  distance  from  the 
building. 

It  is  not  advised  to  directly  connect  private  sewers  with  the  public 
sewer  on  account  of  sewer  gas  from  the  public  sewer.  A  self-cleaning  main 
trap  should  be  placed  in  the  sewer  of  the  building,  with  fresh  air  and  inspection 
openings  at  the  grade  and  vertical  soil  and  waste  pipes  extending  above  the 
roof,  as  described  in  Chapter  XX.  When  several  buildings  of  an  institution 
are  connected  with  a  common  private  sewer,  one  main  trap  and  air  inlet  may 
serve  the  purpose  if  well  placed.  No  sewer  should  be  ventilated  through  a 
down  spout  or  rain  conductor.  Fresh-air  openings  and  sewer  inlets  should 
not  be  close  to  the  building. 

Catch  basins  and  manholes  are  great  filth  an^esters,  and  only  one  catch 
basin  should  be  erected  for  one  building.  A  group  of  buildings  may  also  get 
along  very  well  with  but  one,  if  the  residents  or  inmates  are  prevented  from 
throwing  all  manner  of  filth  and  trash  into  the  sewer.  These  devices  should 
be  as  far  from  the  buildings  as  is  practicable.  If  there  is  a  good  ventilated 
main  trap,  and  soil  pipes  are  extended  above  the  roof  of  all  buildings,  these 
devices  may  be  covered  with  a  metal  lid  instead  of  with  grating. 

Soil  and  waste  pipes  should  not  be  placed  within  ventilating  flues,  as 
gas  may  escape  and  proper  repair  is  almost  impossible. 

Bell  traps  are  not  approved  for  public  buildings  by  the  sanitary  authori- 
ties because  they  have  very  shallow  water  seals  and  are  unsealed  at  the  fre- 


XEW     LXlOX     DEPOT,    \\'ASlIIX(JTOX,    D.C. 

A  LARGE  HEATING  AND  POWER  PLANT  UNDER  A  PAVED  AREA 

A   PUBLIC    BUILDING   MAROONED.       PHILADELPHIA   CITY   HALL 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  23 

quent  intervals  when  it  is  necessary  to  raise  the  covers.  The  Michigan  board 
says  they  "  should  be  relegated  to  the  scrap  heap  at  the  earliest  opportunity." 

When  toilet  rooms  are  placed  in  a  basement  the  ceiling  above  should  be 
impervious  to  air,  and  staircases  should  not  open  from  them  directly  to  the 
floor  above.  Water  closets  should  never  be  placed  in  a  room  unless  it  have 
at  least  one  window  opening  to  the  outside  air. 

When  the  clean-out  pipe  of  a  water  tank  serves  also  as  the  overflow  and 
is  trapped  below  the  tank,  unless  the  tank  overflows  frequently,  evaporation 
lowers  the  seal  and  allows  the  escape  of  gas.  The  overflow  of  a  rain-water 
cistern  should  be  trapped,  but  in  a  dry  season  evaporation  may  break  that 
seal  too.  Consequently,  these  waste  and  overflow  pipes  should  not  discharge 
directly  into  sewers.  The  same  can  be  said  as  to  waste  pipes  from  refrigera- 
tors. 

Some  boards  disapprove  of  the  T  fitting  for  the  branches  in  the  horizon- 
tal sewer,  and  recommend  a  T-Y  or  a  Y  fitting  and  one  eighth  bend.  By- 
passes for  septic  tanks  are  condemned,  as  is  also  the  discharge  of  sludge  from 
the  tank. 

Office  buildings  and  infectious  cases  therein. —  Probably  there  is  no  more 
sanitary  building  than  is  the  modern  concrete  and  iron  office  building. 
However,  in  their  construction  several  things  should  be  remembered  from 
the  sanitary  point  of  viev/.  The  architect  should  first  Idarn  the  depth  of  the 
existing  sewer  and  its  capacity  and  present  load.  These  huge  concrete  build- 
ings require  deep  foundations.  I  have  seen  a  foundation  go  down  twenty 
feet  below  the  sub-basement  and  be  twenty-two  feet  wide  at  the  base.  The 
sub-basement  of  such  a  building  may  be  below  the  level  of  the  existing  sewer, 
or  the  sewer  may  be  too  small  to  serve  the  demands  made  upon  it.  It  is  very 
frequently  the  case  that  an  entirely  new  sewer  may  be  needed,  and  instances 
of  office  buildings  smelling  of  sewer  gas  may  be  due  to  the  owner  refusing  to 
make  adequate  sewer  arrangement.  The  base  of  the  elevator  shaft  may  be 
even  below  the  floor  of  the  sub-basement,  especially  if  an  "  air  cushion  " 
safety  elevator  is  used.  The  pit  for  such  a  shaft  should  be  absolutely  water- 
proof, as  water  collecting  or  seeping  into  such  a  pit  becomes  very  foul  and  may 
contaminate  the  air  of  a  large  portion  of  the  building.  No  sweepings  or  other 
filth  should  be  allowed  in  this  pit,  and  it  should  be  frequently  cleaned.  The 
practice  of  dropping  the  elevator  just  to  show  how  well  the  air  cushion  works 
should  be  abandoned.  While  it  may  not  break  the  eggs  therein,  it  surely 
does  raise  a  dreadful  cloud  of  dust  that  permeates  more  or  less  nearly  the  whole 
building. 

Large  vaults  are  often  constructed  in  public  buildings  and  especially  in 
banking  houses.  They  should  be  based  upon  concrete,  but  it  is  often  noticed 
that  the  floor  and  interior  of  these  vaults  become  damp  and  unhealthy. 
If  the  concrete  base  is  topped  with  slate,  no  moisture  can  reach  the  floor.  An 
electric  fan  should  be  kept  going  in  the  vault  to  provide  ventilation.  Large 
office  buildings  are  usually  erected  upon  very  valuable  land  and  the  heating 
plant  of  the  building  and  the  coal  and  ashes  must  be  all  in  the  cellar.  The 
ideal  way  to  heat  them  is  from  a  central  station  steam-heating  plant.     With 


24  HYGIENE 

such  heating  I  have  some  experience.  The  steam  pipe  is  run  in  from  the 
street  and  the  volume  of  steam  admitted  into  the  system  is  controlled  by  a 
valve  and  lever  arm  upon  which  are  placed  adjustable  weights.  The  radia- 
tors may  be  arranged  most  any  way  demanded  so  there  is  a  good  return  cir- 
culation of  the  condensation  which  is  trapped  off  into  the  sewer.  (See 
Chapter  XX.) 

Little  attention  is  required  for  such  a  system.  It  may  be  kept  uniform 
by  an  electric  thermostat,  a  spring-driven  mechanism  turning  the  steam  on 
and  off.  This  must  be  kept  wound  and  the  battery  cells  charged,  the  trap 
must  be  watched  that  it  does  not  blow  out  its  seal,  and  the  radiators  must  be 
watched  that  they  do  not  fill  up  with  air  or  water.  One  must  give  about  five 
minutes  a  day  to  regulating  and  caring  for  such  an  installation.  It  is  a  sani- 
tary way  to  heat  an  office  building.  Generators  or  boilers  in  the  cellar  may 
or  may  not  be  sanitary  depending  upon  the  man  in  charge.  Wetting  down 
hot  ashes  and  handling  dry  ones  in  such  a  manner  as  to  avoid  vitiating  the 
air  of  the  building  is  something  of  an  art.  If  some  of  the  gentlemen  with 
luxurious  offices  went  to  the  cellar  of  some  of  the  office  buildings,  they  would 
find  that "  Mike  "  kept  his  little  realm  according  to  his  own  code  of  sanitation. 
It  is  the  undergound  parts  of  these  places  that  need  better  sanitation. 

Hand  rails,  door  knobs,  and  other  parts  of  the  inside  construction 
handled  by  the  public  should  be  of  a  character  readily  cleansed  and  of 
material  not  injured  by  antiseptic  solutions.  Plumbing  should  be  ideal, 
since  so  many  persons  spend  so  many  hours  in  these  buildings.  (See  Chapter 
XX  and  the  portion  of  this  chapter  devoted  to  specifications.) 

Lighting  is  an  important  matter.  I  have  an  office  building  in  mind 
where  the  architect  made  the  mistake  of  placing  the  angled  skylight  at  the 
north  side  of  the  building  when  he  could  just  as  well  face  it  south,  where  he 
would  have  secured  more  light.  He  also  provided  no  court  or  area,  since  the 
owner  would  not  sacrifice  the  space,  calculating  that  he  would  have  more 
offices  to  rent  if  he  omitted  an  area.  The  consequence  is  that  one  half  of  the 
building  is  constantly  idle,  and  the  tenants  remaining  are  awaiting  vacancies  in 
office  buildings  provided  with  good  daylight.  The  time  has  come  that  dark 
offices  will  not  rent,  for  business  men  are  going  in  for  sanitary  surroundings. 

It  will  pay  the  owners  of  office  buildings  to  provide  a  room  for  the  espe- 
cial use  of  women  and  where  they  may  eat  lunches,  A  smoking  and  lunch 
room  for  the  men  and  a  dark  room  for  the  use  of  architects  and  others  who  do 
photographic  work,  a  rest  room  for  persons  who  become  ill,  and  a  small 
office  for  a  public  stenographer  and  notary  and  a  few  volumes  therein  of  re- 
ference and  information  needed  in  offices.  The  general  hygiene  of  office 
buildings  will  be  considered  at  the  end  of  this  chapter. 

Infectious  cases  in  office  buildings  should  be  removed  and  the  room 
subject  to  the  contagium  should  be  disinfected  and  closed  from  the  public 
until  after  prolonged  ventilation.  It  should  be  the  especial  care  of  the  sanitary 
authorities  to  trace  up  the  case  and  disinfect  any  of  the  rooms  or  offices  re- 
quiring it.  Office  buildings  have  their  own  weaknesses  from  the  sanitary 
point  of  view,  as  so  many  exposed  papers  of  value  are  difficult  of  disinfection 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  25 

and  the  books  cannot  be  destroyed.  The  office  cat  should  be  banished. 
Adding  machines,  typewriters,  and  other  office  appliances  are  not  readily 
disinfected.  It  is  surpiising  how  much  dirt  accumulates  upon  the  keys  and 
other  portions  of  machinery  coming  in  contact  with  the  fingers.  Careful 
cleaning  with  ammonia  will  remove  finger  marks,  but  care  should  be  used 
not  to  spoil  the  paint.  Telephone  receivers  and  transmitters,  speaking 
tubes,  various  recording  and  time  mechanisms,  and  numerous  small 
articles  apt  to  be  handled  by  the  sick  man,  should  all  be  washed  with  anti- 
septic solutions. 

"The  large  commercial  buildings  and  their  sanitation. —  This  class  of 
structures  are  subject  to  the  general  rules,  but  different  trades  and  lines  of 
business  require  of  the  sanitary  official  a  large  degree  of  initiative  in  deciding 
what  to  do  in  specific  instances.  Fortunately,  most  of  the  persons  visiting 
these  buildings  do  not  remain  long  enough  to  leave  behind  them  any  danger- 
ous elements  of  disease  except  sputum. 

The  laws  governing  the  erection  of  buildings  in  certain  cities  provide 
specifically  as  to  the  specifications  of  this  class  of  buildings.  The  points  cov- 
ered by  law  refer  largel)/  to  the  thickness  of  walls  and  the  method  of  their  con- 
struction, piers,  and  other  supports,  floors  and  the  weight  to  be  placed  upon 
them,  roof  construction,  when  metal  construction  must  be  used,  the  placing  of 
fire  escapes,  the  width  of  stairways,  and  the  other  factors  tending  to  reduce 
the  fire  risk  and  make  exit  safe.  Plumbing  and  other  city  regulations  apply 
to  them,  and  the  general  trend  of  these  laws  are  excellent.  However,  the 
building  experts  are  a  little  apt  to  lay  the  emphasis  upon  height,  to  the  exclu- 
sion of  other  equally  important  matters.  Reference  was  made  under  hotels  to 
the  fact  that  they  may  be  more  carelessly  constructed  in  Harrisburg  than  may 
a  hospital.  Strange  to  say,  the  matter  is  decided  by  height  and  that  is  a  relic 
of  the  time  when  elevators  and  fire  escapes  were  almost  unknown  and  the 
element  of  mere  height  was  more  of  a  potential  danger  than  it  is  to-day.  How- 
ever, our  law  upon  certain  buildings  says: 

Section  IS.  Every  building  hereafter  erected  to  be  used  as  a  hotel  or  a  school- 
house,  the  height  of  which  exceeds  sixty  feet,  and  every  building  hereafter  erected  or 
altered  to  be  used  as  a  hospital,  asylum,  or  institution  for  the  treatment  of  persons, 
the  height  of  which  exceeds  forty-five  feet,  and  every  other  building,  the  height  of 
which  exceeds  seventy-five  feet,  except  grain  elevators  and  buildings  for  which  specifi- 
cations and  plans  have  been  heretofore  submitted  to  and  approved  by  the  proper 
authorities,  shall  be  built  fireproof,  etc. 

That  allows  a  hotel  to  be  a  fire  trap  provided  it  is  59  feet  and  11  inches 
high,  and  the  temptation  is  to  build  them  no  higher.  A  department  store  may 
be  74  feet  and  11  inches  high  and  be  a  tinder  box.  But  a  hospital  45  feet  high 
must  be  what  a  hotel  or  a  department  store  should  be  even  if  only  30  feet  in 
height.  The  regulations  of  most  of  the  eastern  cities  are  on  a  par  with  this, 
just  because  of  precedent  and  the  effort  to  make  old  laws  fit  new  conditions. 
Boards  of  health  need  to  take  up  such  matters  and  secure  modern  provisions. 

Commercial  buildings  are  a  difficult  proposition  as  to  fire  hazard,  and 
everything  is  made  to  bend  to  the  reduction  of  that  hazard.     What  is  regarded 


26  HYGIENE 

as  mere  sanitation  is  apt  to  be  pushed  aside.  The  great  fire  in  Bahimore 
started  in  a  store,  and  as  soon  as  the  roof  fell  in  the  brands  started  fires  in- 
numerable. I  have  seen  many  stores  burn,  and  it  impresses  me  that  the 
building  laws  are  queerly  drawn  as  regards  them.  If  a  big  store  full  of  goods 
takes  fire,  the  interior  is  usually  gutted,  despite  all  the  fire  department  can  do. 
If  the  automatic  sprinkler  system  were  compulsory  few  of  these  fires  would 
get  beyond  control.  As  it  impresses  me,  commercial  and  more  particularly 
mercantile  establishments  and  warehouses  should  be  housed  in  buildings  with 
very  strong  walls  not  liable  to  be  thrown  down  by  fire,  but  the  most  impor- 
tant matter  appears  to  me  to  be  the  fact  that  the  roof  is  almost  always  the 
weak  place,  falls  in,  and  then  things  go  with  a  "  whoof."  Strong  walls  with  a 
roof  made  of  metal  and  clay  tiling  would  keep  together  even  if  rendered  use- 
less by  fire.  The  important  thing  is,  it  would  not  be  so  liable  to  spread.  I 
-was  taken  through  an  "  absolutely  fireproof  "  department  store  in  Pittsburg, 
and  next  week  saw  it  simply  melt  and  crumble  to  a  twisted  mass  of  metal  and 
lime.  The  facts  were,  that  a  fire  in  adjoining  buildings  was  so  hot  that  it 
caused  expansion  of  the  metal  in  the  big  store,  and  the  building  wrecked 
itself  and  its  fine  marble  was  baked  to  lime.  The  progress  of  the  fire  was 
stopped  by  an  ordinary  brick  wall.  Theaters  make  bad  fires,  as  the  laws 
require  that  the  roof  over  the  stage  be  so  arranged  that  burning  a  hempen 
twine  opens  a  skylight.  The  idea  is  to  dispose  of  heat,  smoke,  and  gases,  so 
as  to  save  the  audience,  and  that  is  all  well  enough,  but  I  saw  a  theater  burn 
after  midnight  and  it  surely  was  "  whoof  "  two  minutes  after  the  fire  reached 
the  stage.  I  noticed  brands  next  morning  a  mile  and  a  quarter  away,  and 
only  a  snow  saved  millions  of  dollars'  loss. 

It  seems  to  me  that  stores  and  theaters  could  be  so  constructed  that  great 
columns  of  fire  need  never  twist  out  of  them  and  start  a  cyclone  of  the  devas- 
tating element.  A  brick  wall  will  stand  fire  better  than  will  the  structural 
iron  frame  veneered  over  with  stone  and  filled  in  between  with  brick. 
Heavy  brick  walls  with  the  iron  inside  do  not  throw  themselves  down  when 
heated.  Neither  does  concrete.  The  so-called  "  slow  burning  "  floors  are 
all  that  is  necessary  so  far  as  saving  life  is  concerned.  We  could  save  im- 
mensely in  cost  of  construction  if  we  abandoned  the  idea  that  our  American 
methods  really  made  a  building  fireproof,  and  if  we  would  simply  think  for  a 
moment  we  would  see  that  the  greater  part  of  the  blaze  results  from  the  inflam- 
mable merchandise  in  stock.  No  amount  of  fireproofing  will  prevent  goods 
from  burning. 

The  important  point  to  my  mind  is,  that  //  we  did  not  waste  so  much 
money  in  structural  fads  there  would  be  something  left  to  make  better  provision 
for  safety  and  for  sanitation. 

In  the  South  and  in  parts  of  the  West  commercial  buildings  are  built 
altogether  too  much  of  wood,  and  fires  are  common.  Grain  elevators  are 
made  so  immensely  large  as  to  hold  quantities  of  grain  we  can  ill  aff^ord  to 
lose,  and  every  year  we  read  of  them  going  up  in  smoke.  If  a  war  came  on 
and  the  enemy  wanted  to  cripple  us  most  efi'ectually,  he  would  fire  about  a 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  2T 

hundred  grain  elevators  and  let  us  go  hungry.     It  is  a  mystery  to  me  why  they 
are  built  as  they  are. 

As  a  fine  illustration  of  construction,  the  new  Wanamaker  store  in  Phila- 
delphia favorably  impressed  me,  and  investigation  convinced  me  that  sanita- 
tion was  further  advanced  there  than  in  the  majority  of  our  larger  mercantile 
establishments.  I  asked  Mr.  Joseph  H.  Appel  of  the  store  to  furnish  me  with 
the  sanitary  data  of  the  establishment.     His  paper  upon  the  subject  follows: 

The  sanitary  system  of  the  Wanamaker  store  in  Philadelphia  consists  in  main- 
taining an  adequate  number  of  hygienically  clean  toilet  rooms  (containing  washbasins, 
toilets,  urinals,  sinks,  wastes,  etc.),  a  supply  of  filtered  water  (cooled  for  drinking 
purposes),  a  splendid  ventilating  system,  proper  methods  of  cleaning  and  dusting  the 
store,  judicious  use  of  disinfectants,  and  instruction  of  the  employes  in  the  observance 
of  hygienic  rules. 

The  sanitary  provision  made  in  regard  to  toilet  rooms,  both  for  employees  and 
customers,  begins  with  the  construction  of  these  rooms.  The  toilet  rooms  are  large,, 
well-ventilated  compartments,  the  floors  and  partitions  of  which  are  marble,  and  the 
walls  and  ceilings  marble  and  plaster.  Natural  ventilation  is  assisted  by  suction  pipes 
which  exhaust  vitiated  air.  The  floors,  walls,  and  partitions  are  cleaned,  and  the 
toilets  themselves  are  cleaned  with  antiseptic  solutions  many  times  a  day.  The 
toilets  are  of  the  most  modern  type,  and  very  frequent  flushings  do  not  depend  on  the 
individual  using  them. 

Attendants  who  are  constantly  present  see  to  it  that  this  high  degree  of  cleanliness 
is  maintained. 

Stationary  washstands,  soap,  and  towels  are  supplied  in  each  room. 
Number  of  toilet  rooms  and  washbasins: 

EMPLOYEES         Closets 
Men  54 

Women  70 

CUSTOMERS 

Men  31 

Women  99 

Ventilation. — The  ventilating  system  of  the  basement,  the  basement  mezzanine,, 
and  the  sub-basement,  consists  of  air  being  removed  by  suction,  while  fresh  air,  which 
is  washed  pure,  is  pumped  in,  the  air  being  completely  changed  every  six  minutes. 

The  construction  of  the  building,  with  the  light  shaft  in  the  center,  together  with 
high  ceilings  and  high  and  wide  windows,  permits  a  free  and  natural  ventilation  above 
these  floors. 

The  heating  plant  being  entirely  separate  from  the  building  is  a  factor  in  keeping 
the  air  clean  and  fresh. 

Thoroughly  filtered  water  is  supplied  at  frequent  and  convenient  localities  through- 
out the  store.  The  water  used  for  drinking  purposes  is  cooled  by  refrigeration,  and 
is  in  constant  circulation  through  the  pipes. 

The  employees  are  instructed  regarding  personal  and  general  cleanliness  by 
means  of  literature  placed  in  their  hands  by  the  management  of  the  store. 

The  medical  director,  who  has  charge  of  the  general  health,  hygiene,  and  sani- 
tation of  the  employees,  spends  one  half  of  each  day  in  the  store. 


inals 

Washbasins 

34 

45 

47 

21 

15 

61 

28  HYGIENE 

Questions  of  sanitation  and  hygiene  are  presented  each  day,  and  individuals  are 
instructed  and  advised.  In  addition  to  this,  physical  instruction  is  given  by  highly 
competent  instructors  and  drill  masters. 

The  drills  of  the  cadets  (boys  and  girls)  of  the  battalion,  the  outdoor  life  of  the 
boys  in  camp,  of  the  girls  in  camp,  the  field  sports  and  athletic  teams,  are  all  im- 
portant factors  in  the  high  hygienic  standard  attained  among  the  employees. 

Stores  especially  need  regulation,  since  so  many  of  them  are  found  in 
slum  districts  and  are  no  better  than  their  surroundings.  With  many  kinds 
of  merchandise  sanitation  is  not  affected,  but  foods  are  a  vital  matter.  The 
Ladies'  Home  Journal  started  a  crusade  against  dirty  groceries.  The  editor 
should  inspect  some  of  the  stores  conducted  by  foreigners.  The  reader  can 
imagine  the  conditions.  However,  some  of  the  most  exclusive  and  elaborately 
finished  confectionery  stores  in  the  country  refuse  to  place  their  goods  under 
glass  or  screens  because,  as  explained  to  me  by  the  proprietor  of  one  of  them, 
"  Our  wealthy  patrons  would  think  we  feared  they  might  help  themselves 
free  to  an  occasional  bon-bon."  I  watched  awhile  and  found  the  "  wealthy 
patrons  "  were  fully  able  to  help  themselves  while  fondly  imagining  the  pro- 
prietor would  not  even  it  up  on  the  semi-annual  bill.  The  District  of  Colum- 
bia provides  as  follows,  to  protect  food  from  contamination: 

Section  14.  Every  manager  of  a  store,  market,  dairy,  cafe,  lunch  room,  or  any 
other  place  in  the  District  of  Columbia,  where  a  food  or  a  beverage  or  confectionery 
or  any  similar  article  is  manufactured  or  prepared  for  sale,  stored  for  sale,  offered  for 
sale,  or  sold,  shall  cause  it  to  be  screened  effectually,  or  effectually  protected  by  power- 
driven  fan  or  fans,  so  as  to  prevent  flies  and  other  insects  from  obtaining  access  to  such 
food,  beverage,  confectionery,  or  other  article,  and  shall  keep  such  food,  beverage, 
confectionery,  or  other  article  free  from  flies  and  other  insects  at  all  times.  Any  person 
violating  the  provisions  of  this  regulation  shall,  upon  conviction  thereof,  be  punished 
by  a  fine  of  not  more  than  twenty-five  dollars  for  each  and  every  such  offense.  This 
regulation  shall  take  effect  from  and  after  the  expiration  of  thirty  days  immediately 
following  the  date  of  its  promulgation. 

Official  copy  furnished  health  department. 
By  order: 

WM.  TINDALL,  Secretary 

Officially  published  in  the  Washington  Herald,  April  16,  1908. 

Market  houses  are  a  specialty  here  in  Pennsylvania,  and  they  are  a 
wonder  of  wonders  to  Western  friends  I  take  especial  pride  in  astonishing, 
for  it  takes  a  great  deal  to  astonish  the  Westerner.  But  the  Pennyslvania 
markets  are  a  wonder,  for  we  people  eat  everything  ever  heard  of  and  then 
some  we  only  know  about  ourselves.  How  the  pure  food  laws  would  classify 
some  of  the  "  Dutch  dishes  "  we  buy  "  made  aretty  "  is  a  mystery  to  me.  So 
far  as  I  can  see,  the  pure  food  people  never  try,  and  yet  our  markets  in  the 
larger  cities  provide  better  produce  than  one  is  able  to  buy  in  the  small  towns 
adjacent  to  the  farms.  It  must  be  good  to  sell  at  market,  and  what  will  not 
sell  is  peddled  through  the  country  and  villages.  People  living  in  the  small 
towns  come  here  to  market.  Short  weight  and  measure  are  common  in  the 
markets,  as  well  as  forestalling,  but  the  produce  is  nearly  always  good.     I 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  29 

have  seen  markets  in  the  South  and  they  are  fairly  good,  but  have  a  less  va- 
riety to  sell  and  are  not  so  well  housed.  In  very  few  instances  have  I  seen  any 
effort  to  screen  food  exposed  for  sale  in  market  houses.  The  stalls  are  not  as 
clean  as  they  should  be,  and  the  places  are  usually  crowded,  as  the  effort  is 
made  to  place  as  many  stalls  in  a  small  building  as  can  possibly  be  accommo- 
dated.    Most  cities  need  legislation  concerning  their  markets. 

It  is  unnecessary  to  enter  at  length  into  the  vending  of  food  here,  as  the 
chapter  upon  pure  food  and  drugs  covers  the  subject.  Also,  the  hygiene  of 
such  commercial  buildings  will  be  covered  under  the  last  heading  in  this 
present  chapter. 

Two  classes  of  establishments  may  well  be  considered  here,  the  barber 
shop,  so  commonly  found  in  hotels,  and  the  laundry.  I  have  taken  occasion 
to  ask  barbers  their  opinion  of  legislation  governing  their  work,  and  all  to 
whom  I  have  spoken  are  either  opposed,  are  ignorant  of  the  dangers,  or  are 
indifferent  to  the  matter. 

Barber  shops. —  Ever  since  1903  Utah  has  had  a  board  of  examiners 
for  barbers,  consisting  of  tvv^o  barbers  and  one  physician,  and  the  act  is  very 
full  in  its  requirements,  one  section  of  which  is  here  reproduced. 

Section  10.  How  certificate  obtained. —  Any  person  desiring  to  obtain  a  certifi- 
cate of  registration  under  this  act  shall  make  application  to  said  board  therefor,  and 
shall  pay  to  the  treasurer  of  said  board  an  examination  fee  of  five  dollars,  and  shall 
present  himself  at  the  next  regular  meeting  of  the  board  for  the  examination  of  appli- 
cants, whereupon  said  board  shall  proceed  to  examine  such  person;  and  being  satis- 
fied that  he  is  above  the  age  of  sixteen  years,  of  good,  moral  character,  free  from 
contagious  or  infectious  diseases,  that  he  had  either  studied  the  occupation  for  one 
year  as  an  apprentice  under  a  qualified  practicing  barber,  or  that  he  has  studied  the 
occupation  in  a  barber  school  or  schools  as  defined  by  this  act  for  one  year,  or  has 
practiced  the  occupation  in  another  state  for  at  least  one  year,  and  is  possessed  of  a 
requisite  skill  in  said  occupation  to  properly  perform  all  the  duties  thereof,  including  his 
ability  in  the  preparation  of  tools,  shaving,  hair  cutting,  and  all  the  duties  and  services 
incident  thereto,  his  name  shall  then  be  entered  by  the  board  in  the  register  hereinafter 
provided  for,  and  a  certificate  of  registration  shall  be  issued  to  him  authorizing  him 
to  practice  said  occupation  in  cities  of  the  first  and  second  class  in  this  state;  Provided, 
that  whenever  it  appears  that  the  applicant  has  acquired  his  knowledge  of  said  occu- 
pation in  a  barber  school,  the  board  may  subject  him  to  an  examination  and  withhold 
from  him  a  certificate  if  it  shall  thus  appear  that  he  is  not  qualified  to  practice  the  said 
occupation. 

Licenses  may  be  revoked  upon  conviction  of  crime,  habitual  drunk- 
enness, gross  immorality,  incompetence,  and  violation  of  the  provisions 
of  the  law.  Several  other  states  have  legislated  upon  the  subject  and,  where 
well  tried  out,  the  barbers  of  the  better  class  seem  to  approve  the  law.  Some 
barbers  in  states  having  no  laws  upon  the  subject  are  reported  as  practically 
observing  the  usual  requirements  of  such  laws.  The  weak  point  in  the 
sanitation  of  a  barber  shop  is  the  strop  upon  which  the  razor  is  sharpened. 
There  is  no  effective  method  for  sterilizing  these  leather  strops. 


30  HYGIENE 

The  regulations  governing  shops  vary  somewhat,  but  those  of  the  District 
of  Columbia  are  as  full  as  any  that  have  come  into  my  hands.  They  are  here 
reproduced : 

Executive  Office 

Commissioners  of  the  District  of  Columbia 

Washington,  May  28,  1906 
Ordered: 

That  the  health  ordinances  of  the  District  of  Columbia  be,  and  they  are  hereby, 
amended  by  adding  thereto  the  following: 

Regulations  for  the  control  of  barber  shops  in  the  District  of  Columbia. 

1.  Every  manager  of  a  barber  shop  that  is  in  operation  at  the  time  of  the  pro- 
mulgation of  these  regulations  shall,  on  or  before  September  1,  1906,  register  his  full 
name  and  the  location  of  said  shop  in  a  book  to  be  kept  in  the  health  office  for  that 
purpose;  and  every  manager  of  a  barber  shop  that  is  first  opened  for  business  after  the 
promulgation  of  these  regulations  shall  within  five  days  after  the  opening  of  said 
shop  register  in  like  manner.  In  event  of  a  change  in  the  manager  or  in  the  location 
of  any  barber  shop  aforesaid,  the  manager  of  said  shop  shall  call  at  the  health  office 
within  five  days  after  such  change  takes  place  and  make  a  corresponding  entry  in  the 
register. 

2.  The  owner  and  the  manager  of  any  barbershop,  and  each  of  them,  shall  equip 
said  shop  and  keep  said  shop  equipped  with  running  hot  and  cold  water  and  with  all 
such  appliances,  furnishings,  and  materials  as  may  be  necessary  to  enable  persons  em- 
ployed in  and  about  said  shop  to  com.ply  with  the  requirements  of  these  regulations. 

3.  No  owner  and  no  manager  of  a  barber  shop  shall  knowingly  permit  any  person 
suffering  from  a  communicable  skin  disease  or  from  a  venereal  disease  to  act  as  a 
barber  in  said  shop. 

4.  No  person  who  to  his  own  knowledge  is  suffering  from  a  communicable  disease 
or  from  a  venereal  disease  shall  act  as  a  barber. 

5.  Every  manager  of  a  barber  shop  shall  keep  said  shop  and  all  furniture,  tools, 
appliances,  and  other  equipments  used  therein  at  all  times  in  a  cleanly  condition. 

6.  Every  manager  of  a  barber  shop  shall  cause  all  combs,  hair  brushes,  hair 
dusters,  and  analogous  articles  to  be  washed  thoroughly  at  frequent  intervals,  and  to 
be  kept  clean  at  all  times,  and  shall  cause  all  mugs,  shaving  brushes,  razors,  shears, 
scissors,  clippers,  and  tweezers  to  be  sterilized  from  time  to  time  as  hereinafter  provided. 

7.  No  barber  shall  use  for  the  service  of  any  customer  a  comb,  hairbrush,  hair 
duster  or  any  analogous  article  that  is  not  thoroughly  clean,  nor  any  mug,  shaving 
brush,  razor,  shears,  scissors,  clippers,  or  tweezers  that  are  not  thoroughly  clean,  or 
that  have  not  been  sterilized  since  last  used. 

8.  Every  barber  immediately  after  using  a  mug,  shaving  brush,  razor,  scissors, 
shears,  clippers,  or  tweezers  for  the  service  of  any  person,  shall  sterilize  the  same  by 
immersing  them  in  boiling  water  for  not  less  than  a  minute  or,  in  the  case  of  razors, 
scissors,  shears,  and  tweezers,  by  immersing  them  for  not  less  than  ten  minutes  in  a 
five  per  cent  aqueous  solution  of  carbolic  acid,  or  in  alcohol  of  a  strength  not  less  than 
sixty-five  per  cent. 

9.  No  barber  shall  use  for  the  service  of  a  customer  any  towel  or  wash  cloth  that 
has  not  been  boiled  and  laundered  since  last  used. 

10.  Every  barber  shall  cleanse  his  hands  thoroughly  immediately  before  serving 
each  customer. 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  31 

11.^  No  barber  shall,  to  stop  the  flow  of  blood,  use  alum  or  other  material  unless 
the  same  be  used  as  a  powder  or  liquid,  and  applied  on  a  clean  towel  or  in  a  similar 
manner. 

12.  No  barber  shall  use  a  powder  pufF,  a  sponge,  or  a  finger  bowl  for  or  in  the 
service  of  a  customer. 

13.  No  barber  shall  permit  any  person  to  use  the  head  rest  of  any  barber's  chair 
under  his  control  until  after  the  head  rest  had  been  covered  with  a  towel  that  has  been 
washed  since  having  been  used  before,  or  by  clean,  new  paper. 

14.  No  barber  shall  shave  any  person  when  the  surface  to  be  shaved  is  inflamed 
or  broken  out,  or  contains  pus,  unless  such  person  be  provided  with  a  cup  and  lather 
brush  for  his  individual  use. 

15.  No  barber  shall  undertake  to  treat  any  disease  of  the  skin. 

16.  No  person  shall  use  a  barber  shop  as  a  dormitory,  nor  shall  any  owner  or 
any  manager  of  a  barber  shop  permit  said  shop  to  be  so  used. 

17.  Any  person  violating  any  of  the  provisions  of  these  regulations  shall,  upon 
conviction  thereof,  be  fined  not  more  than  twenty-five  dollars, 

18.  The  owner  and  the  manager  of  any  barber  shop,  and  each  of  them,  shall 
keep  a  copy  of  these  regulations,  to  be  furnished  by  the  health  officer,  posted  in  said 
shop  for  the  information  and  guidance  of  persons  working  or  employed  therein. 

19.  The  word  "  barber  "  as  used  in  these  regulations  means  any  person  who 
shaves  or  trims  the  beard,  or  cuts  or  dresses  the  hair  of  any  other  person  for  pay,  and 
includes  "  barbers'  apprentices  "  and  shop  boys.  The  word  "  manager  "  means 
any  person  having  for  the  time  being  control  of  the  premises  and  of  persons  working 
or  employed  therein. 

By  order: 

WILLIAM  TINDALL,  Secretary 
Officially  published  in  the  Washington  Times,  June  1,  1906. 

Laundries. —  Establishments  with  modern  machinery  are  usually  in  a 
fair  sanitary  condition.  The  buildings  in  which  some  of  them  do  business 
are  far  from  sanitary,  and  the  constant  exposure  to  steam  is  not  conducive 
to  health  in  the  operatives.  So  far  as  the  patron  is  concerned  his  linen  usually 
comes  back  quite  sterile,  since  the  washer  is  run  at  practically  boiling  tem- 
perature, the  mangle  or  hand  iron  is  very  hot,  and  the  methods  of  drying  are 
usually  by  centrifugal  machine  or  by  superheated  steam  or  drying  closet  kept 
very  clean.  The  danger  is  from  laundries  doing  hand  work.  The  Chinese 
laundries  vary  much  according  to  the  character  of  the  patronage.  The 
average  Chinaman  "  aims  to  please  "  and  is  very  quick  to  respond  to  demands 
necessary  to  achieve  the  American  dollar.  The  "  wash  lady  "  is  the  real 
offender  and  not  always  by  choice.  These  women  work  hard  for  a  living  and 
often  must,  perforce  of  untoward  environment,  do  their  washing  and  drying 
in  places  wretched  enough  and  not  conducive  to  sanitary  laundry  work. 
However,  so  long  as  no  contagious  disease  exists  upon  the  premises,  the 
danger  is  slight.  There  should  be  a  registration  of  these  small  laundries  as 
per  the  following: 


32  HYGIENE 

Commissioners  of  the  District  of  Columbia 

HEALTH  DEPARTMENT 

Regulation  Requiring  the  Registration  of  Laundries 

That  every  person  who  commonly  launders  for  pay  on  the  premises  which  he  or 
she  occupies,  the  clothing,  or  the  sheets,  pillow  cases,  table  cloths,  napkins,  or  other 
similar  articles,  belonging  to  any  other  person  or  persons,  shall  report  that  fact  to  the 
health  officer  in  writing  within  thirty  days  after  this  regulation  takes  effect,  giving 
his  or  her  name  and  the  location  of  his  or  her  premises,  and  the  number  of  person  or 
families  living  independently  of  one  another  whom  he  or  she  serves,  if  less  than  ten  in 
number;  and  thereafter  every  person  laundering  as  aforesaid  shall  report  in  like 
manner  his  or  her  name,  and  the  location  of  his  or  her  premises,  and  the  number  of 
persons  or  families  whom  he  or  she  serves,  within  five  days  after  the  beginning  of  his 
or  her  occupancy  of  such  premises  and  the  use  thereof  for  the  purposes  aforesaid. 
Any  person  violating  any  of  the  provisions  of  this  regulation  shall,  upon  conviction 
thereof,  be  punished  by  a  fine  of  not  more  than  twenty-five  dollars. 

Order  of  Commissioners  of  July  22,  1908,  as  amended  by  order  of  August  7, 1908 

Churches  and  schools. —  Chapter  III,  upon  "  Schools  and  Colleges,"  as 
well  as  Chapter  XVIII,  upon  "  Disinfection,"  give  so  much  data  upon  school 
sanitation  that  little  need  be  said  upon  the  matter  here.  The  construction  of 
school  buildings  is  being  carefully  studied,  and  the  death  by  fire  of  a  large 
number  of  children  in  a  school  building  has  stimulated  the  matter  of  school 
safety.  Stairs  and  exits  of  proper  construction  and  a  constantly  used  fire 
drill  will  almost  always  prevent  loss  of  life  except  by  explosion.  Too  many 
school  buildings  have  wooden  ceilings  and  construction  so  full  of  cracks  and 
joints  that  adequate  disinfection  is  almost  impossible.  Every  schoolroom 
should  be  provided  with  artificial  light  for  use  during  cloudy  weather.  Need- 
less to  say,  the  plumbing  and  the  drinking  vessels  should  be  above  reproach. 
The  specifications  in  the  earlier  portion  of  this  chapter  and  the  plumbing 
regulations  appearing  in  Chapter  XX,  as  well  as  the  remarks  upon  the  hygiene 
of  large  buildings  near  the  close  of  this  chapter,  all  apply  to  schools. 

It  was  not  so  very  long  ago  that  the  peculiar  warped  ideas  of  the  then 
dominant  theology  stood  directly  in  the  way  of  church  sanitation,  but  men  and 
ideas  of  larger  caliber  have  banished  the  prejudice  against  heating  a  church, 
properly  furnishing  them,  and  the  use  of  unfermented  wine  and  individual 
cups  at  the  sacrament.  It  is  now  generally  recognized  that  churches  and 
Sabbath  schools  may  spread  contagion,  and  they  are  rapidly  coming  under 
regulation.  However,  the  church  schools  (probably  excepting  parochial 
schools)  are  not  sufficiently  careful  to  exclude  children  from  families  under 
quarantine.  I  know  very  well  that  children  with  whooping  cough  and  the 
milder  infectious  diseases  often  are  not  excluded.  Church  officials  are  not 
wholly  to  blame,  as  they  may  not  be  notified  of  disease  in  their  families. 
There  should  be  a  space  in  report  cards  giving  the  names  of  the  day  and 
Sabbath  schools  attended  by  the  patient  and  members  of  the  household 
involved  in  the  report.     Superintendents  of  all  Sabbath  schools  should  be 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  ^3 

notified  of  such  cases  by  the  local  health  board.  In  some  places  this  is  done. 
Churches  are  very  hard  to  disinfect.  The  size  and  height  of  the  auditorium 
and  the  many  openings  for  ventilation  and  ceiling  lights,  as  well  as  the  large 
number  of  Bibles  and  hymn  books  in  racks,  all  make  the  practical  difficulties 
very  great.  Formaldehyde  generators  have  been  used,  but  they  do  not  liber- 
ate the  gas  fast  enough  to  attain  sufficient  concentration  before  most  of  it 
escapes.  Probably  the  best  method  consists  in  filling  the  building  v^ith  steam 
and  then  touching  off^  at  once  a  dozen  milk  pails  charged  according  to  direc- 
tions for  the  formalin-permanganate  method  described  in  Chapter  XVIII. 
The  persons  emptying  the  formalin  upon  the  permanganate  must  have  a  pre- 
arranged signal  for  that  act  and  must  leave  the  room  on  the  run.  Sufficient 
chemicals  to  do  a  thorough  job  cost  quite  a  sum,  and  the  gas  is  liable  to 
escape  so  soon  that  additional  precautions  should  be  taken,  consisting  of  an 
elaborate  cleaning  with  bichloride  solution.  Books  had  better  be  taken  into 
a  small  room,  strung  upon  cords  or  wires,  and  subjected  to  full  formalin  per- 
manganate disinfection.  In  a  small  and  tight  room  the  gas  will  not  escape 
so  readily. 

Opera  houses. —  The  writer  has  been  looking  for  an  opera  house  or 
theater  that  is  ideal,  from  the  hygienic  point  of  view,  and  has  not  found  it 
thus  far.  Many  theaters  are  all  right  from  the  standpoint  of  the  audience, 
but  the  actor  has  a  different  story  to  tell.  The  larger  cities  have  building 
laws  requiring  theaters  and  opera  houses  to  be  of  fireproof  construction  and 
with  fireproof  division  walls,  doors,  properties,  curtain,  stairways,  and  all 
scenery  that  can  be  made  so.  These  regulations  call  for  fire  escapes  of  the 
best  pattern,  and  every  precaution  to  empty  the  building  of  smoke  and  to 
prevent  the  spread  of  fire  is  defined  in  the  rules.  Lighting  and  ventilation  is 
regulated  and  automatic  sprinklers  must  be  freely  installed  at  all  points  of 
danger. 

Some  smaller  cities,  like  Harrisburg,  have  copied  these  regulations 
verbatim  et  llteratum,  and  because  land  does  not  cost  so  much  have  erected 
theaters  in  advance  of  the  run  of  the  large  city  playhouses.  Aside  from  defec- 
tive ventilation  and  drafts  the  audience  is  safe  and  comfortable  in  buildings 
constructed  along  these  modern  lines  unless  there  are  three  tiers  above  the 
main  floor,  when  the  upper  tiers  become  too  warm  for  comfort  and  often  the 
air  is  vitiated  near  the  ceiling.  Little  could  be  added  to  better  provide  for  the 
safety  of  the  audience  In  the  new  opera  houses  of  the  cities  with  adequate 
building  laws  that  are  enforced.  But  many  theaters  are  presenting  their 
attractions  in  old  buildings  patched  up  to  cover  the  letter  of  the  law.  Some 
of  the  more  celebrated  theaters  in  our  larger  cities  are  gilded  shells.  It  is 
time  the  public  refused  to  patronize  these  places.  Procure  a  copy  of  the 
building  laws  of  your  city,  and  you  will  probably  be  amazed  at  the  require- 
ments that  are  gradually  allowed  to  become  dead  letters.  However,  matters 
theatrical  are  improving,  and  It  will  not  be  many  years  before  the  poorly 
constructed  houses  will  be  a  thing  of  the  past. 

Actors  and  small  amusement  halls  are  considered  in  Chapter  VI,  but  It 
is  incumbent  upon  me  here  to  say  that  the  dressing  rooms  and  accommoda- 


34  HYGIENE 

tions  for  the  talent  employed  in  the  large  theaters  is  almost  if  not  quite  uni- 
versally inadequate  and  insanitary.  These  quarters  are  adequate  for  a  small 
company,  but  when  a  grand  opera  company  or  a  spectacular  attraction  or  a 
comic  opera  with  a  large  chorus  tries  to  make  up  for  their  acts,  with  twenty 
or  thirty  people  to  a  room,  it  is  no  wonder  if  an  occasional  actor  forgets  the 
amenities  of  civilized  society  and  acts  outside  as  he  is  compelled  to  do  in  his 
dressing  room.  Putting  the  whole  menagerie  into  one  cage  is  about  as  edi- 
fying to  them  as  it  is  to  ladies  and  gentlemen  who  happen  to  be  theatrical 
people  to  be  jammed  together  in  a  way  the  lower  animals  would  resent. 

I  practiced  medicine  for  eight  years  next  door  to  a  theater,  and  can  assure 
my  readers  that  the  rank  and  file  of  theatrical  talent  are  ladies  and  gentlemen 
compelled  to  fight  hard  against  the  common  impression  of  their  depravity, 
and  hustled  along  and  crowded  regardless  of  the  sensitive  feelings  outraged 
daily  by  what  they  have  to  endure  to  hold  their  jobs.  They  need  to  apply 
union  rules  and  demand  that  they  be  given  better  accommodations  and  enforce 
it  by  refusing  to  act  in  any  new  opera  house  failing  to  supply  them. 

Industrial  establishments. —  This  class  of  buildings  might  well  be  dis- 
cussed here,  but  as  Chapter  XXII,  upon  "  Public  Works  and  Corporations," 
treats  of  so  many  industries  and  occupation  diseases,  the  whole  may  just  as 
well  be  grouped  together  in  the  later  chapter. 

Hygiene  and  disinfection  of  large  buddings. —  Disinfection  is  included 
here  merely  to  afford  opportunity  to  refer  to  the  chapter  upon  disinfection, 
the  one  upon  schools  and  colleges,  that  upon  local  boards  of  health,  and  the 
heading  "  Churches  and  Schools  "  in  this  chapter.  Full  data  regarding 
disinfection  can  be  found  in  these  places. 

As  to  the  hygiene  of  large  buildings,  we  will  not  repeat  here  the  data 
given  in  discussing  schools,  colleges,  hospitals,  sanitoria,  hotels,  penal  in- 
stitutions, etc.     Some  general  rules  onl}  will  be  given  as  a  mere  index. 

All  premises  must  be  drained,  cisterns  and  water  containers  screened, 
proper  lighting  and  ventilation  supplied,  good  water  secured,  be  swept  daily 
when  few  persons  are  in  the  building,  dusted  ditto,  floor  scrubbed  once  a 
week,  signs  must  be  posted  prohibiting  spitting  except  into  cuspidors  cleaned 
daily  and  containing  six  ounces  disinfecting  solution  when  in  use. 

All  plumbing  must  be  good  and  kept  clean.  Tuberculous  employees 
must  be  given  work  not  bringing  them  into  intimate  contact  with  others. 
Windows  should  be  screened,  especially  in  hospitals.  No  burlap,  cocoa 
matting,  or  sacking  cloth  may  be  used  for  floor  covering,  as  they  cannot  be 
adequately  disinfected. 

Hospitals  should  disinfect  rooms  regularly  every  three  months  and 
immediately  after  the  recovery  of  infectious  diseases.  AU  stairs,  corridors, 
etc.,  should  be  scrubbed  with  antiseptic  solution  every  few  days  or  scrubbed 
after  sprinkling  with  a  solution.     Toilet  rooms  should  be  scrubbed  daily. 

Hotels  and  restaurants  should  take  especial  care  of  the  ice  box  or  re- 
frigerator; they  should  be  kept  free  from  rats,  garbage  should  be  carefully 
handled,  and  a  grease  trap  should  be  provided. 


A    MODEL    SANITARY    OFFICE    BUILDING 

Exterior  and  central  skylighted  court,  The  Larkin  Co.,  Administration, 
Building,  Buffalo,  N.  Y. 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  35 

Finally,  nearly  everything  in  this  book  applies  to  the  hygiene  of  some 
kind  of  public  building  or  to  the  comfort  and  wellbeing  of  the  inmates. 

A  Sanitary  Office  Building 

While  the  present  writer  has  found  many  large  office  buildings  models  in 
arrangement  and  kept  scrupulously  clean,  the  reverse  is  niore  common  than 
might  be  anticipated.  In  the  larger  cities  and  in  offices  largely  visited  by  the 
public,  as  well  as  in  large  corporation  offices,  conditions  are  usually  good, 
but  in  isolated  places  or  those  closed  to  the  public  there  is  less  incentive  to 
erect  and  to  properly  maintain  modern  and  sanitary  construction  and  appli- 
ances. 

Nevertheless,  I  have  visited  so  many  creditable  office  buildings  that  I 
was  at  a  loss  to  select  one  to  illustrate  the  points  already  outlined  as  neces- 
sary for  hygienic  office  work.  While  in  Buffalo,  N.  Y.,  I  found  opportunity 
to  visit  the  Larkin  Company's  factories,  a  series  of  large  structures,  with  fifty 
acres  of  floor  space,  and  where  I  mistakenly  supposed  they  made  nothing  but 
soap.  Across  the  street  therefrom  I  noted  a  tall,  massive  building  in  the 
midst  of  a  pretty  lawn.  I  confess  it  never  occurred  to  me  that  it  might  be 
an  office  made  after  twentieth-century  plans,  but  such  it  was.  The  Larkin 
Company  claims  it  is  the  finest  and  most  complete  private  office  building  in 
the  world.  Certainly  it  is  by  far  the  most  sanitary  one  it  has  ever  been  my 
pleasure  to  study,  and  next  to  the  new  office  building  of  the  Capitol  at  Wash- 
ington the  most  up  to  date  structure  I  have  found  filled  with  desks.  By 
courtesy  of  the  Larkin  Company,  the  following  description  and  illustrations 
are  given.  It  is  true  there  are  public  or  governmental  office  buildings  with  a 
much  more  ornate  interior,  but  I  commend  for  imitation  the  sanitary  features 
of  the  Larkin  offices. 

The  Larkin  Company  has  paid  particular  attention  to  housing  its  employees  in 
healthful,  pleasant  surroundings.  The  administration  building  has  capacity  for 
eighteen  hundred  workers.  Viewed  from  the  outside,  the  building  is  massive  and 
austere;  the  interior  is  in  direct  contrast.  It  is  light  in  color  and  restful  in  effect.  A 
great,  skylighted  central  court  extends  upward  from  the  first  floor  to  the  roof.  It 
admits  an  abundance  of  daylight  to  all  parts  of  the  five  floors.  The  windows  are 
hermetically  sealed  with  double  glass,  so  that  smoke,  dust,  and  noise  are  excluded. 
Fresh  air  is  drawn  in  at  the  roof,  forced  to  the  basement,  and  washed  by  passing 
through  a  sheet  of  water  sprays  which  remove  ninety-eight  per  cent  of  the  dirt,  dust, 
and  impurities.  The  spraying  reduces  the  temperatures  of  the  air  in  the  summer. 
In  the  winter  the  air  is  heated.  Then  it  is  circulated  throughout  the  building  and 
exhausted  from  beneath  the  great  skylight. 

The  building  is  absolutely  fireproof.  Window  frames,  desks,  chairs,  and  filing 
cabinets  are  of  metal.  The  flooring  and  stairways  are  of  a  fireproof  composition 
known  as  magnesite.  As  much  attention  was  given  to  providing  an  office  that  could 
be  kept  clean  and  sanitary  as  to  providing  a  place  in  which  business  could  be  trans- 
acted conveniently.  Wherever  possible,  partitions  are  free  of  the  floor;  the  toilet 
closets  and  their  enclosures  are  arranged  so,  and  with  few  horizontal  joints  anywhere 
in  which  dirt  may  lodge.  The  metal  lockers  and  metal  desks  have  metal  bases  that 
touch  the  floor  at  intervals  only.  The  chairs  are  swung  free  of  the  floor  onto  the  desk 
legs. 


36  HYGIENE 

The  main  building  contains  five  floors  (six,  including  the  basement).  Four 
floors  and  part  of  the  basement  are  given  over  to  business.  The  top  floor  contains 
assembly  hall,  kitchens,  and  the  restaurant  in  which  the  employees  are  fed  at  cost 
prices.     The  roof  is  a  recreation  ground  with  conservatories  and  tiled  promenade. 

An  annex  to  the  main  structure  contains  rest  rooms,  lounging  rooms,  toilet  and 
bathrooms,  and  quarters  for  the  trained  nurse  who  is  on  duty  at  every  business  session. 
Employees  have  the  privilege  of  consulting  the  nurse  and  using  the  rest  rooms  when 
indisposed.  Those  who  are  unable  to  report  for  work  are  visited,  and  those  who  need 
help  receive  it. 

The  Larkin  Company  administers  its  welfare  work  on  the  plan  of  helping  those 
who  help  themselves;  it  does  not  essay  to  be  a  father  and  a  mother  to  its  employees. 
An  educational  offer  makes  it  possible  for  any  employee  who  is  a  student  in  a  public 
class  of  instruction  to  be  reimbursed  for  tuition  and  expenses  by  attaining  a  standing 
of  seventy-five  per  cent  or  more  in  work,  and  ninety  per  cent  or  more  in  attendance. 
The  company  also  refunds  to  employees  the  cost  of  books  purchased  and  twice  read, 
of  which  the  purchasers  write  brief  synopses  which  show  thorough  reading. 

The  business  sessions  are  from  8  to  12  and  1  to  5  daily,  with  Saturday  half  holidays 
from  June  to  September.  A  department  for  employees'  savings  that  pa)'s  five  per  cent 
interest,  compounded  quarterly,  is  maintained  for  the  employees,  and  there  is  a  sick 
benefit  association  in  which  membership  is  voluntary. 

The  New  Union  Station,  Washington,  D.  C. 

The  Union  Station  is  situated  at  the  northern  edge  of  the  Capitol  Hill 
terrace,  the  natural  terrace  having  been  artificially  extended  to  the  north 
prior  to  the  erection  of  the  edifice.  A  large  plaza  occupies  the  space  south 
of  the  station,  the  foundation  of  which  is  higher,  and  the  building  itself  is  at  a 
considerable  distance  from  any  structure  in  this  section  of  the  city.  By 
reason  of  this  elevation  and  the  surrounding  open  space,  the  air  is  less  vitiated 
and  breezes  from  all  directions  are  more  frequent  than  could  otherwise  occur 
in  the  heart  of  the  city. 

A  high  vaulted  arcade  occupies  to  a  considerable  elevation  three  sides 
of  the  main  structure,  the  great  concourse  (the  largest  in  the  world)  which 
might  be  considered  an  exaggerated  arcade  occupies  the  remaining  side  at  the 
north.  The  north  side  of  the  concourse  is  open  at  all  times.  This  arrange- 
ment of  arcades  permits  the  free  circulation  of  air  in  all  directions. 

The  high  vaulted  main  waiting  room  occupies  to  a  great  extent  the  cen- 
tral part  of  the  main  structure,  communicating  by  numerous  large  doorways 
and  windows  with  the  concourse  and  with  the  east  and  south  arcades.  The 
method  of  heating  this  room  is  unique.  The  air  is  drawn  in  near  the  main 
entrance  through  two  large  shafts,  and  passes  between  the  sides  of  a  series 
of  vertical  heated  pipes,  then  through  a  large  mesh  cylinder  revolving  above 
a  vat  of  w^ater,  which  submerges  the  lower  portion  of  the  cylinder;  dust  and 
other  particles  floating  in  the  air  are  thus  caught,  and  the  air  cleaned  to  this 
extent  passes  from  the  cylinder  to  another  chamber  w-here  it  is  superheated 
and  forced  into  the  main  waiting  room  through  registers  at  either  extremity 
of  each  bench. 


LARGE    OFFICE,    LARKIN    CO.,    ADMINISTRATION     BUILDING 


READING    ROOM    FOR    EMPLOYEES;      EIGHTEEN    HUNDRED    IN    THE    OFFICES 

Many  firms  are  doing  welfare  work  such  as  this 


HOTELS,  LODGING  HOUSES,  PUBLIC  BUILDINGS  37 

An  unusually  large  number  of  doors  and  windows  assist  in  the  ventilation 
of  the  building,  which  process  is  completed  by  numerous  air  shafts  which 
extend  from  the  main  floor  to  a  distance  above  the  roof;  a  fan  operates  near 
the  top  of  each  shaft.  These  air  shafts  and  fans  are  found  to  be  of  particular 
value,  especially  in  improving  the  ventilation  of  the  restaurants  and  kitchen. 

All  offices  are  cleaned  by  the  vacuum  process,  and  the  cars,  toilet  rooms, 
cuspidors,  and  other  vessels  about  the  station  are  disinfected. 

The  shops  and  roundhouses  are  at  a  great  distance  from  the  station,  which 
is  used  only  for  passenger  service;  no  freight  trains  pass  near  or  stop  at  the 
edifice. 

The  system  of  plumbing  and  sewerage  meets  the  most  advanced  sanitary 
requirements. 


Chapter  III 
SCHOOL  INSPECTION  AND  COLLEGE  SANITATION* 

A  practical  presentation  of  the  duties  of  the  school  medical  inspector  and  the 
school  nurse  in  both  the  large  and  the  small  city  —  Exclusion  of  infectious  cases,  the 
tuberculous  teacher,  defectives  and  degenerates,  and  other  problems  —  Sanitation 
of  buildings  —  The  tobacco  problem  —  The  hygiene  of  athletic  sports  —  Sexual  and 
venereal  instruction  for  young  men  in  college —  College  training  in  sanitation — Nurses' 
training  schools. 

MEDICAL  inspection  of  school  children,  while  comparatively  an 
innovation,  is  nov^  permanently  established  in  over  two  hundred  cities 
throughout  the  United  States,  and  will  probably  soon  be  compulsory 
in  most  states.  It  comprises  three  distinct  objects,  viz.  (1)  the  recognition 
and  isolation  of  all  pupils  affected  with  any  communicable  disease.  This  is 
accomplished  by  daily  examination.  (2)  Routine  examination  for  the  pur- 
pose of  detecting  any  deficiencies  that  may  retard  the  pupil  in  school  work 
or  hinder  proper  physical  growth.  (3)  Examination  of  the  schools  as  to  hy- 
giene and  sanitary  condition  of  the  premises. 

Two  working  systems  of  medical  inspection  are  made  use  of;  one  in 
which  all  three  previously  named  elements  are  employed  and  another  in 
which,  while  all  are  kept  in  view,  only  the  second  or  routine  examination  is 
properly  carried  into  effect,  the  others  being  reached  only  incidentally.  The 
ideal  system  is  naturally  the  first,  where  all  objects  are  attained,  but  this 
is  possible  only  in  a  large  city  or  where  the  health  officers  are  willing  to  incur 
the  necessary  expense. 

An  attempt  will  be  made  to  formulate  a  correct  working  plan  for  the  two 
systems,  taking  that  adapted  for  the  smaller  city  first. 

One  physician,  devoting  from  one  to  two  hours  each  school  day  and  as- 
sisted by  one  nurse,  can  take  care  of  from  six  to  eight  thousand  pupils 
during  an  ordinary  school  year.  The  work  may  be  done  more  thoroughly 
and  very  much  better  results  may  be  attained  by  having  two  nurses. 

So  many  requests  have  come  to  our  school  board  for  sets  of  the  blanks 
used  here  that  the  entire  set  is  reproduced  at  the  end  of  this  section.  Suffice 
it  to  say  that  these  blanks  were  not  devised  until  after  those  in  use  in  many 
cities  were  studied,  and  they  have  only  recently  reached  their  perfected  form 
after  due  trial  of  varying  features.     They  have  proven  very  satisfactory. 

The  office  work  of  school  inspection  should  be  done  at  the  general  offices 
of  the  school  board,  so  that  records,  names,  and  addresses  are  available. 
The  nurse  will  then  prepare  cards  for  a  special  schoolroom,  filling  Form  M, 
1 — 1.  This  makes  a  permanent  record  of  data,  as  shown  by  the  card,  and 
usually  cards  are  prepared  for  every  pupil  in  the  building. 

In  making  the  initial  examination  one  of  two  methods  may  be  used,  the 
first  to  have  all  of  the  pupils  in  a  building  examined  in  one  vacant  room  in 
groups  of  six,  or  to  examine  in  the  individual  schoolrooms.     After  trying  both 

*By  Chas.  S.  Rebuck,  M.D.,  and  the  Editor. 


SCHOOL  INSPECTION  AND  COLLEGE  SANITATION  39 

methods,  the  latter  plan  has  been  found  preferable  here.  The  examiner 
should  stand  with  his  back  to  a  window  and  at  twenty  feet  distance  is  placed 
the  card  for  eye  tests.  Be  sure  the  distance  is  measured.  All  pupils  above 
the  first  year  use  Snellin's  E  Card.  Smaller  children  use  a  number  card, 
such  as  is  used  for  the  illiterate.  Examinations  of  the  mouth  and  throat 
make  individual  wooden  tongue  depressors  imperative,  and  the  teachers  must 
be  instructed  to  have  them  promptly  destroyed.  Towels  must  also  be  sup- 
plied for  the  examiner.  The  nurse  calls  out,  from  the  previously  prepared 
cards,  the  names  of  the  children  in  order,  and  they  pass  before  the  examiner, 
who  notes  quickly  the  state  of  nutrition,  the  condition  of  the  cervical  glands, 
any  deformity  of  limbs  or  spine,  skin  eruptions  upon  exposed  portions  of  the 
body,  and  any  characteristic  abnormality.  Then  with  the  wooden  tongue 
depressor  the  conditions  of  the  teeth  and  throat  are  noted,  as  well  as  the 
tonsils  and  the  presence  or  absence  of  post-nasal  discharges.  This  is  fol- 
lowed by  an  examination  of  the  heart  and  lungs,  superficially  noting  all  cases 
except  those  presenting  valvular  lesions  or  lung  troubles  of  moment.  With 
the  child's  back  to  the  window  the  vision  is  tested,  each  eye  being  tested 
separately  by  holding  a  card  over  the  other.  Much  time  can  be  saved  by 
having  the  teacher  point  to  the  letters  upon  the  eye  card.  If  the  child  can  see 
distinctly  all  the  characters  or  letters  in  the  |^  and  |^  line  with  each  eye,  and 
there  is  no  visible  strabismus,  vision  is  considered  normal.  Finally  the 
acuteness  of  hearing  is  tested  by  having  the  child  close  the  eyes  and  testing 
each  ear  separately  by  holding  a  watch  at  a  distance  of  about  three  feet. 
Any  defect  found  is  called  to  the  nurse  by  its  proper  number  according  to 
the  following  code.     She  enters  the  numbers  and  date  upon  the  record  card. 

CODE 

1  Malnutrition  11  Defective  Hearing 

2  Enl.  Car.  Glands  12  Def.  Nasal  Breathing 

3  Chorea  13  Teeth  Defective 

4  Cardiac  Disease  14  Defor.  Palate 

5  Pulmon.  Disease  15  Hyper.  Tonsils 

6  Skin  Disease  16  Adenoids 

7  Defective  Spine  17  Mentality 

8  Defective  Chest  18  Spec.  Infec.  Disease 

9  Defective  Extrem.  19  Defec.  Speech 
10  Defective  Vision 

After  some  experience,  from  thirty  to  fifty  children  may  be  examined  in 
one  hour.  After  retiring  from  the  room  the  nurse  records  upon  a  blank  form 
already  noted  the  clinical  data  elicited,  as  well  as  filling  the  "  Room  Report." 
From  this  list  she  prepares  the  recommendation  card  to  parent  or  guardian 
(Form  Ml  —  3)  and  the  physician's  reply  post  card  (Ml  — 9).  These  are 
both  given  the  same  serial  number  and  mailed  in  a  sealed  envelope. 

To  the  writer's  mind,  the  most  important  feature  of  medical  inspection 
is  the  "  follow  up  "  system,  without  which  real  good  will  be  seldom  accom- 
plished.    Whenever  the  physician's  reply  card  is  not  received  within  two 


40  HYGIENE 

weeks  from  the  date  of  mailing,  a  nurse  will  visit  that  home,  explain  the  need 
of  proper  treatment  and  urge  the  same.  If  among  the  very  poor,  the  igno- 
rant, or  the  foreign  population,  she  will  administer  treatment  to  minor  skin 
affections,  or  for  matters  of  greater  difficulty  take  the  child  to  a  hospital  dis- 
pensary. This  personal  visitation  is  productive  of  much  good,  and  at  the 
same  time  she  is  often  able  to  instruct  the  family  in  many  points  of  personal 
hygiene  and  sanitation. 

In  a  city  of  from  thirty  thousand  to  sixty  thousand  population,  two 
nurses  and  one  inspector  are  able  to  pretty  thoroughly  cover  the  ground  as 
to  routine  examinations  during  a  school  year.  However,  in  this  system 
the  primal  object  of  medical  inspection  is  lost  sight  of  to  a  large  extent;  that 
is,  the  daily  visitation  for  the  detection  of  communicable  disease. 

An  ideal  system  amply  comprehensive  to  cover  the  needs  of  medical  in- 
spection could  be  maintained  by  using  one  physician  for  about  fifteen  hundred 
pupils,  employing  the  same  cards  and  follow  up  plan.  Form  Ml  —  2  is  used 
in  any  event  when  contagion  exists.  Each  inspector  would  visit  the  build- 
ings assigned  to  him  at  a  definite,  prearranged  time  every  day.  At  that  hour 
the  teachers  would  have  sent  to  a  vacant  room  all  cases  having  been  absent 
more  than  a  day  and  returning  without  a  doctor's  certificate,  all  cases  com- 
plaining of  not  feehng  well,  and  all  suspects,  who  would  then  be  examined 
and  suspects  or  communicable  cases  excluded.  This  would  require  probably 
twenty  minutes  at  each  of  his  buildings,  and  the  remainder  of  his  time  would 
be  devoted  to  the  line  of  work  already  described,  and  which  greater  time 
would  allow  him  to  do  more  thoroughly. 

The  following  rules  will  be  found  helpful  where  daily  inspections  are 
made: 

INSTRUCTIONS  TO  MEDICAL  INSPECTORS  OF  PUBLIC  SCHOOLS 

1.  The  pupils  to  be  inspected  will  be  referred  to  the  inspectors  by  the  principal 
for  two  reasons; 

A.  Those  who  have  been  absent  one  or  more  days. 

B.  Those  in  the  school  whom  the  teacher  may  suspect  to  be  suffering  from 

communicable  diseases. 
These  two  classes  must  be  kept  separate  in  the  reports. 

2.  The  inspection  is  to  be  made  with  reference  to  communicable  diseases  only, 
and  pupils  are  to  be  excluded  for  the  following  diseases: 

Scarlet  Fever  Chicken-pox 

Diphtheria  Whooping-cough 

Tonsillitis  Pediculosis 

Measles  Ring  Worm 

Roetheln  Impetigo 

Mumps  Scabies 
Smallpox 

or  other  communicable  diseases  of  the  skin  and  scalp,  and  communicable  diseases  of 
the  eye. 


SCHOOL  INSPECTION  AND  COLLEGE  SANITATION  41 

3.  In  making  throat  examinations,  the  wooden  tongue  depressors  supplied 
must  be  used  to  the  exclusion  of  all  other  depressors.  EACH  TONGUE  DEPRES- 
SOR MUST  BE  USED  ONCE  ONLY.  Aseptic  methods  must  be  employed  in 
all  examinations. 

4.  Whenever  a  child  is  excluded,  brief  but  sufficient  reason  therefor  must  be 
written  on  the  exclusion  card. 

5.  Medical  inspectors  will  use  their  own  judgment  about  the  acceptance  of  family 
physician's  certificates.  You  have  the  right  to  ignore  them  if  such  action  is  justified 
by  your  personal  investigation  of  a  case  at  school. 

6.  The  PRINCIPAL  excludes  children  from  school,  the  inspector  RECOM- 
MENDS to  the  principal  exclusions  when  justified,  the  principal  acts  accordingly. 
Do  your  utmost  to  maintain  harmony  and  co-operation  with  principals. 

7.  Be  sure  and  give  exclusion  cards  in  every  instance,  so  parents  will  be  notified. 

8.  Remember  you  have  no  jurisdiction  as  inspector  beyond  the  threshold  of  the 
public  schools  of  your  district.  DO  NOT  examine  pupils  at  your  office  or  any  place 
outside  of  the  public  schools. 

The  following  are  the  regulations  in  use  by  the  writer  in  the  exclusion  of 
communicable  cases. 

SANITARY  REGULATIONS 

The  following  Sections  of  the  Rules  and  Regulations  of  the  School  District  of 
the  city  of  Harrisburg,  Pa.,  give  information  concerning  the  Sanitary  Regulations 
governing  the  schools  of  the  city. 

These  Regulations  were  adopted  by  the  Board  of  School  Directors,  September 
7,  1906. 

D.  D.  HAMMELBAUGH,  Secretary 


Section  233.  No  pupil  or  teacher  afl^ected  with  any  contagious  or  infectious 
disease,  or  directly  exposed  to  the  same,  shall  be  allowed  to  attend  schools. 

Section  234.  The  following  diseases  are  classified  as  contagious  or  infectious, 
in  the  intention  of  the  preceding  section:  Cholera,  smallpox  (variola  or  varioloid), 
scarlet  fever,  scarlet  rash,  typhus  fever,  yellow  fever,  relapsing  fever,  diphtheria 
(diphtheritic  croup),  leprosy,  epidemic  cerebro  spinal  meningitis  (spotted  fever), 
whooping  cough,  measles,  German  measles,  mumps,  and  chicken  pox. 

Section  235.  Pupils  or  teachers  sufi^ering  with  or  residing  in  families  having 
cholera,  smallpox,  scarlet  fever,  scarlet  rash,  typhus  fever,  yellow  fever,  relapsing 
fever,  diphtheria,  or  leprosy,  shall  be  excluded  from  school  for  a  period  of  thirty  days 
following  the  discharge  by  removal  or  recovery  of  the  person  last  afflicted  in  said 
house  or  family,  and  the  thorough  disinfection  of  the  premises;  and  all  such  children 
or  teachers,  before  being  permitted  to  attend  or  return  to  school,  shall  furnish  to  the 
principal  a  certificate  signed  by  the  medical  attendant  of  said  children  or  persons, 
and  countersigned  by  an  officer  of  the  sanitary  department,  setting  forth  that  the 
thirty  days  mentioned  in  this  section  have  fully  expired. 

Section  236.  Pupils  and  teachers  suffering  with  whooping  cough,  measles,  Ger- 
man measles,  mumps,  or  chicken  pox,  shall  be  excluded  from  school  until  recovery; 
those  residing  in  families  having  any  of  the  diseases  named  in  this  section,  but  who 
may  not  have  contracted  said  disease,  shall  be  excluded  from  school  for  a  period  of 
twenty-one  days  after  the  first  onset  of  the  disease  in  the  house  or  family;    and  all  such 


42  HYGIENE 

children  or  teachers,  before  returning  to  school,  shall  furnish  to  the  principal  a  cer- 
tificate signed  by  a  physician,  or,  in  cases  where  no  physician  has  been  in  attendance, 
by  an  authorized  health  officer,  setting  forth  that  the  above  provision  has  been  complied 
with,  and  that  proper  precautions  have  been  taken  for  the  prevention  of  the  spread 
of  the  disease. 

Section  237.  Pupils  and  teachers  suffering  with  or  residing  in  families  having 
epidemic  cerebro  spinal  meningitis  (spotted  fever)  shall  be  allowed  to  return  to  school 
only  upon  the  certificate  of  attending  physician  setting  forth  recovery  of  the  individual, 
and  that  all  proper  precautions  have  been  taken  for  the  prevention  of  the  spread  of  the 
disease. 

Section  238.  Children  affected  with  tonsillitis,  pediculosis  capitis  (head  lice), 
pediculosis  corporis  (body  lice),  and  all  forms  of  contagious  skin  or  eye  diseases,  such 
as  scabies  (itch),  impetigo  contagiosa,  favus,  tinea  circinata  (ring  worm),  erysipelas, 
trachoma,  and  acute  contagious  conjunctivitis  (pink  eye),  shall  be  excluded  from 
school  until  recovery  as  certified  to  by  a  physician.  This  section  applies  only  to  per- 
sons actually  affected,  and  not  to  other  persons  living  in  the  household  or  family. 

Section  239.  Teachers  are  directed  to  insist  upon  cleanliness  and  neatness  in 
personal  appearance  of  pupils,  and  those  who  are  wilfully  and  habitually  negligent 
in  this  respect  may  be  sent  home  with  an  explanation  to  the  parents  or  guardian 
of  the  cause  of  dismissal,  and  admission  may  be  refused  until'they  are  suitably  prepared 
for  school. 

Section  232.  No  pupil  shall  be  received  into  any  school  except  upon  a  certificate 
signed  by  a  physician  setting  forth  that  such  child  has  been  successfully  vaccinated, 
or  has  previously  had  smallpox. 

Some  differences  of  opinion  exist  as  to  the  line  of  demarcation  between 
the  duties  of  inspectors  and  nurses.  The  nurse  is  of  inestimable  value  in  the 
Work,  and  of  the  two  probably,  by  her  personal  contact  with  parents,  does  the 
greater  work.  In  administration  she  must  be  under  the  inspector.  In  brief 
her  work  consists  of  clerical  duties,  visiting  the  schools  with  the  inspectors, 
home  visiting,  instructing  parents  how  to  carry  out  certain  lines  of  treatment, 
treating  certain  skin  diseases,  and  teaching  personal  hygiene  and  household 
sanitation. 

As  the  prevention  and  cure  of  tuberculosis  is  rapidly  coming  to  the  front, 
so  the  proper  disposition  of  tubercular  teachers  and  pupils  must  be  met. 
Many  school  boards,  like  ours  here  with  a  teacher's  retirement  fund,  now 
require  a  physical  examination  of  all  applicants  for  the  position  of  teacher, 
more  or  less  along  the  line  of  life  insurance  examinations.  Our  blank  here 
is  reproduced  and  is  similar  to  that  used  elsewhere.  Naturally  this  examina- 
tion precludes  a  tubercular  teacher  beginning  the  work.  If  cases  develop 
among  the  force,  so  long  as  the  case  is  incipient  and  curable  and  the  teacher 
will  adhere  to  rigid  rules  as  to  expectoration,  the  use  of  paper  napkins,  etc., 
the  sufferer  is  not  dismissed,  but  given  leave  of  absence,  if  practicable,  so  as 
to  enter  a  sanitorium.  Careless  teachers  or  scholars  suffering  from  incipient 
tuberculosis  are  excluded  from  the  schools.  While  in  many  states  no  legal 
warrant  is  given  for  excluding  the  tubercular,  a  little  tact  will  bring  it  about, 
as  a  rule. 

A  problem  of  increasing  importance  in  the  larger  cities  is  that  of  the  care 
of  mentally  deficient  children.     Probably  one  per  cent  of  city  public  school 


SCHOOL  INSPECTION  AND  COLLEGE  SANITATION         43 

pupils  are  defective  or  degenerate.  In  many  instances  this  is  due  to  some 
physical  defect,  such  as  adenoids,  or  to  improper  environment,  and  when  these 
are  corrected  the  child  soon  becomes  normal.  But  in  many  instances  it  is 
purely  a  mental  defect.  It  has  been  demonstrated  that  a  majority  of  these 
children  improve  markedly  under  proper  care  and  training  and  later  lead 
useful  lives.  This  requires  special  schools,  with  teachers  who  have  been 
scientifically  trained  in  their  work. 

As  will  be  observed,  the  set  of  blanks  now  presented  are  very  largely 
self  explanatory,  and  their  reproduction  gives  in  graphic  form  what  would 
take  many  pages  for  me  to  present  didactically.  These  forms  are  adapted 
to  most  places,  but  boroughs  should  not  be  discouraged,  since  a  creditable 
work  can  be  done  along  very  simple  lines,  while  highly  elaborated  systems 
may  require  a  greater  number  of  reports. 

I  wish  to  say,  in  closing,  that  the  work  is  interesting,  has  justified  itself 
by  results  in  Harrisburg,and  seems  to  be  appreciated  by  the  patrons  of  the 
schools.     Relatively  speaking,  the  cost  is  insignificant. 


PHYSICAL  RECORD 


Name Nationality 

Parent  (Guardian) Building. 


Treatment 
Date  of  Age         Grade  Code  Number  of  any  Advised 

Examination  Defect  Found  (Yes  or  No) 


CODE 

1  Malnutrition.  2  Enl.  Cer.  Glands.  3  Chorea.  4  Cardiac  Disease.  5 
Pulmon.  Disease.  6  Skin  Disease.  7  Defective  Spine.  8  Defective  Chest.  9  De- 
fective Extrem.  10  Defective  Vision.  11  Defective  Hearing.  12  Def.  Nasal 
Breathing.  13  Teeth  Defective.  14  Defor.  Palate.  15  Hyper.  Tonsils.  16  Ade- 
noids.    17  Mentality.     18  Spec.  Infec.  Disease.     19  Defec.  Speech. 

Obverse  Physical  Record 


This  card  must  be  filed  by  teacher  and  transferred  with  pupil  through  succeeding 
grades. 

Address  of 
Parent 


REMARKS 
Reverse  Physical  Record 


44  HYGIENE 

Date 

is    ordered    to     discontinue    attendance 

at  the School  Building,  until  he  or  she  presents  to  the 

principal  a  certificate  from  a  physician,  showing  him  or  her  to  be  free  from  any  con- 
tagious or  infectious  disease,  and  that  no  danger  of  contagion  exists  at  home. 

Reason 


Medical  Inspector 

This  notice  does  NOT  exclude  this  child  from  school. 

No 

Date 

A  physical  examination  seems  to  show  that 


has. 

For  his  or  her  future  welfare  and  proper  progress  in  school  work,  you  should 
consult  your  family  physician  as  to  proper  treatment;  or,  if  unable  to  pay,  take  the 
child  to  a  Hospital  Dispensary. 


Medical  Inspector 
TAKE  THIS  CARD  WITH  YOU  TO  THE  FAMILY  PHYSICIAN 


Form  M  1—4 

ROOM  REPORT  of  Pupils  Having  Some  Defect 

Building Grade Teacher 

Treatment 
NAME  Date  Advised         Case  No.  REMARKS 

(Yes  or  No) 


Form  M  1—5 

DAILY  AND  MONTHLY  REPORT  OF  MEDICAL  INSPECTOR 

No. 
Date  BUILDING      Routine  No.  No.  Special  Total  No. 

Exam.        Re-exam.  Exam.  Exam, 


No.  Contagious 
or  Infectious         No.  Showing         No.  Requiring       No.  Defective       No.  Excluded 
Diseases  some  Defect      Medical  Attention  Conditions  found 


Medical  Inspector 
Obverse  Report  of  Medical  Inspector 


SCHOOL  INSPECTION  AND  COLLEGE  SANITATION 


45 


Summary  from to. 

Total  No.  routine  examinations 

re-examinations 

special 

examined 

contagious  or  infectious  diseases   

showing  some  defect 

requiring  medical  attention 

excluded 

defective  conditions  found 


Defects  for  which  treatment  has 
been  recommended 


Malnutrition  

Enl.  cervical  glands 

Chorea  

Cardiac  disease 

Pulmonary  disease 

Skin  disease    

Defective  spine 

Defective  chest  

Defective  extremities 

Defective  vision  

Defective  hearing 

Defective  nasal  breathing . 
Teeth  requiring  attention.. 

Deformed  palate  

Hyper,  tonsils  

Adenoids 

Deficient  mentality  

Specific  infectious  disease. 
Defective  speech 


No.  reporting  treatment  during  month. 


Condition  for  which  Treatment  has 
been  instituted 


REMARKS 


Reverse  Report  of  Medical  Inspector 


Form  M  1—6 

DAILY  AND  MONTHLY  REPORT  OF  SCHOOL  NURSE 


Date         Buildings  Visited  No.  Homes  Visited 


No.  Children  Attended 
in  Homes 


No.  Calls  Made 


No.  Attended  in  School 


No.  taken  to  Dispensary 
or  Hospital 


Obverse  Report  of  School  Nurse 


School  Nurse 


46  HYGIENE 


Summary  from to. 


Total  No.  schools  visited 

"         "    homes  visited  

"         "    children  attended  in  homes 

"         "    calls  made 

"         "    attended  in  school 

"         "     taken  to  Dispensary  or  Hospital 


Class  of  Cases  Visited  in  Homes  Time^devoted  to  clerical  work 

Malnutrition  "  "       "  inspection    .. 

Enl.  cervical  glands "  "       "    visiting 

Chorea Total  time 

Cardiac  disease 

Pulmonary  disease REMARKS 

Skin  disease  

Defective  spine 

Defective  chest  

Defective  extremities 

Defective  vision  

Defective  hearing 

Defective  nasal  breathing 

Teeth  requiring  attention 

Deformed  palate  

Hyper,  tonsils 

Adenoids 

Deficient  mentality  

Specific  infectious  disease 

Defective  speech 

Reverse  Report'^of^School  Nursk 


Form  M  1—7 


INSTRUCTIONS  TO  TEACHERS 


Prior  to  the  examination  of  scholars  the  nurse  will  furnish  a  blank  form,  on 
which  shall  be  written  the  names  of  all  pupils  in  the  room. 

Any  child  who  appears  to  be  backward  in  school  work,  or  shows  signs  of  physical 
deficiency,  such  as  mouth  breathing,  poor  vision,  defective  hearing,  foul  breath, 
or  any  skin  eruption,  shall  be  given  a  slip  of  paper,  to  be  handed  to  inspector,  with 
its  name,  and  the  nature  of  the  defect  stated  thereon. 

These  slips  must  NOT  be  given  to  children  until  time  of  examination. 

Medical  Inspector 


SCHOOL  INSPECTION  AND  COLLEGE  SANITATION  47 

Form  M  1—8 

THE  FOLLOWING  METHOD  OF  TREATMENT  FOR  KILLING  LICE  AND  NITS 
IS  RECOMMENDED 

Wet  the  hair  thoroughly  with  crude  petroleum,  of  which  half  a  pint  may  be  ob- 
tained at  a  drug  store.  Keep  it  wet  for  three  hours;  then  wash  the  whole  head  with 
warm  water  and  soap.  Repeat  this  process  on  three  successive  days.  The  nits 
may  then  be  removed  by  combing  the  hair  very  carefully  with  a  fine-toothed  comb 
wet  with  vinegar.  Repeat  the  combing  for  several  days  until  no  more  nits  can  be 
found.  To  make  the  treatment  easier  and  the  more  thorough,  the  hair  may  be  cut 
short,  if  there  is  no  objecvion. 

All  persons  in  a  family  are  likely  to  be  affected,  and  should  also  be  treated  as 
above.  Brushes  and  combs  should  be  cleansed  by  putting  them  in  boiling  water  for 
a  few  minutes. 


TAKE  THIS  CARD  TO  YOUR  PHYSICIAN 


No. 


The  physician  consulted  will  kindly  sign  and  forward  this  card  after  examining 
child. 

I  have  this  day  examined 

and  have. advised  treatment. 

Respectfully, 


Date 


DAILY  MEMORANDUM  FOR  MEDICAL  INSPECTOR 


Date 

School 

No.  routine  examinations 

No.  re-examinations 

No.  special  examinations 

No.  contagious  diseases 

No.  showing  some  defect 

No.  requiring  medical  attention 

No.  defective  conditions    

No.  excluded 

Remarks: 


48  HYGIENE 

DAILY  MEMORANDUM  FOR  SCHOOL  NURSE 

Date 

School  visited _ 

No.  homes  visited    „ 

No.  children  attended  in  homes 

No.  calls  made 

No.  attended  in  school    _ 

No.  taken  to  dispensary _ _ _. 

Time  devoted  to  clerical  work 

Time  devoted  to  inspection _ _ 

Time  devoted  to  visiting  

Remarks: 

REPORT  OF  MEDICAL  EXAMINER  ON  APPLICANT  FOR 
POSITION  AS  TEACHER 

1 .  Name  in  full _ 

Date  of  birth „ 

2.  Family  History: 

Living  Dead 

Age        Age  Cause  of  Death 

Father 

Father's  father 

Father's  mother ...„ „ 

Mother 

Mother's  father 

Mother's  mother 

Brothers    _ _ 


Sisters 


3.     State  what  serious  illness,  if  any,  you  have  have  had  during  the  past  ten  years  .? 


4.  Name  your  medical  attendant, 

May  the  school  board  refer  to  him  ? 

5.  To  what  extent  do  you  use  alcoholic  drinks 

To  what  extent  do  you  use  tobacco,  and  in  what  form  .'' 

The  foregoing  answers  are  full,  complete,  and  true. 
Date 


Applicant 


UNIVERSITY    OF    MICHIGAN    GYMNASIUM 

SCHOOL    NURSE    AT    WORK,    NEW    YORK    CITY 

A    MEDICAL    COLLEGE    ANATOMICAL    LABORATORY 

Properly  separated  from  other  departments 


SCHOOL  INSPECTION  AND  COLLEGE  SANITATION  49 

6.  Weight _„. Height 

Girth  of  chest  at  full  expiration „ _ 

Girth  of  chest  at  full  inspiration _ — _ _ 

7.  Frequency  of  pulse „ - - 

Frequency  of  respiration  _ 

8.  Is  there  any  evidence  of  disease  of  _ 

Brain  or  nervous  system _ - 

Heart  or  lungs - - — 

Sromach  or  abdominal  organs „ 

Rheumatism  - _ - 

9.  Vision :    Right  eye „ — ..     Left  eye  ....„ 

Hearing :    Right  ear Left  ear _ 

(Snellin'sTest  Type  to  be  used  in  testing  vision;  the  closed  vpatch  in  testing 

hearing.) 

10.  Has  applicant  been  successfully  vaccinated  ?    

11.  Urinalysis: 

Color _ _ - — 

Reaction  „ _ _ _ — - 

Specific  gravity — - 

Sugar _ _ 

Albumen „ _ - 

12.     Do  you  advise  the  acceptance  of  the  applicant  ? _ — 

The  preceding  answers  and  examination  of _ _ _ — 

_ are  correct  to  the  best  of  my  knowledge 

Date „...„ 


Medical  Examiner 


Sanitation  of  buildings. —  In  Chapters  II  and  XX  the  construction  and 
sanitation  of  buildings  is  fully  discussed,  while  the  chapters  upon  Disinfection 
and  Quarantine  relate  much  of  importance  in  this  connection.  School  build- 
ings have  especial  need  for  frequent  disinfection.  The  drinking  cup  is  of 
sanitary  importance  in  the  school.  Several  plans  have  been  suggested  tor 
avoiding  the  dangers  of  promiscuous  use  of  the  same  cup.  Here  in  Hams- 
burg  we  are  installing  drinking  founts  made  like  the  sanitary  scuttle  butts  of 
the  United  States  navy.  They  are  very  satisfactory  where  municipal  water 
plants  exist.  In  rural  districts  individual  cups  are  advised  and  can  be  kept 
in  the  child's  desk.  Paper  or  paraffined  cups  are  satisfactory,  but  the  total 
cost  of  supplying  them  is  considerable  of  an  item.  The  same  must  be  said 
of  paper  napkins  or  towels. 

Every  teacher  should  be  charged  with  the  task  of  instructing  scholars  to 
refrain  from  kissing,  sucking  pencils  or  pens,  or  passing  them  around,  trading 
chewing  gum,  eating  apples  or  confectionery  that  have  been  in  the  mouths 
of  other  children,  and  should  any  insanitary  habits  or  customs  arise  among  the 


50  HYGIENE 

scholars  the  teacher  should  tactfully  take  the  matter  in  hand.  City  school 
children  are  often  restricted  in  their  playgrounds.  (See  the  remarks  upon 
playgrounds  under  "  Parks  "  in  the  chapter  upon  "  Places  of  Amusement  and 
Dissipation.") 

The  accommodations  for  toilet  purposes  at  rural  schoolhouses  are  often 
abominable.  In  the  chapter  upon  "  Rural  Hygiene  "  a  proper  arrangement 
is  pictured  and  described.  This  is  a  matter  of  the  very  greatest  importance 
in  the  country.  Especially  is  this  true  in  view  of  the  fact  that  hookworm 
disease  is  kept  up  in  whole  communities  from  the  defective  sanitation  at  rural 
schoolhouses.  This  disease  is  really  a  fearful  scourge  in  the  South  and 
readers  should  study  this  disease  and  the  means  of  its  dissemination  most 
carefully.  See  the  index  of  this  book  for  several  references  thereto,  and  it  is 
also  shown  in  a  drawing  in  the  Appendix.  Marion  Hamilton  Carter  has 
written  a  splendid  paper  upon  hookworm  disease,  and  it  is  found  in  the 
October,  1909,  number  of  McClure's  Magazine,  under  the  caption:  "The 
Vampire  of  the  South."     From  it  I  quote: 

On  a  plantation  in  South  Carolina  sixty  hands  were  employed,  all  infected  with 
hookworms,  several  of  them  in  severe  degree,  and  all  from  the  same  obvious  cause  — 
no  sanitary  convenience.  In  another  state,  thirty  per  cent  of  all  the  rural  school- 
houses  were  without  closets, —  in  some  entire  counties  no  rural  schools  had  any, — 
and  the  soil  for  a  radius  of  one  hundred  and  fifty  feet  about  each  of  these  schools  was 
infested  with  hookworm  ova  and  larvae.  Superficial  examination  of  the  school  chil- 
dren in  one  district  showed  seventy  to  eighty  per  cent  of  them  infected,  many  of  them 
very  badly.  These  school  percentages  are  about  three  times  those  of  the  adult  and 
twice  those  of  the  non-school  going  population  in  the  regions  from  which  the  schools 
draw,  the  school,  as  a  hotbed  of  infection,  being  nearly  double  in  potency  the  one- 
horse  farm. 

There  are  asserted  to  be  two  million  cases  of  hookworm  infection  in  the 
United  States,  and  its  history  is  that  the  negroes  brought  it  from  Africa,  are 
relatively  immune  to  it  themselves,  although  eighty  per  cent  of  Southern 
negroes  are  asserted  to  have  the  disease,  and  are  disseminating  it  among 
the  whites,  to  whom  no  degree  of  immunity  has  been  established.  At  all 
events  it  is  a  dreadful  scourge  in  several  states,  and  dirty  communities  along 
the  Mason  and  Dixon  line  are  liable  to  outbreaks,  and  it  may  even  come 
further  North.  I  have  seen  what  wretched  toilet  accommodations  are  com- 
mon, not  only  in  the  South,  but  also  in  portions  of  the  North  in  and  about 
rural  schoolhouses.  Every  physician  who  is  in  country  practice  should  look 
into  the  matter  in  his  own  district.  I  used  to  practice  in  the  country  and 
know  how  hard  it  is  to  wake  up  some  rural  school  boards,  but  keeping  ever- 
lastingly at  it  even  brings  them  to  time. 

Academies  and  colleges  are  often  housed  in  most  insanitary  buildings, and 
especial  attention  should  be  called  to  overcrowding  in  colleges.  Most  of  these 
institutions  are  hampered  for  room,  and  two  students  are  housed  where  one 
should  be,  especially  in  the  dormitories. 

Nowadays  the  public  schools  are  so  well  looked  after  where  there  are 
adequate  boards  of  health,  that  it  is  time  to  turn  to  some  of  the  colleges  and 


SCHOOL  INSPECTION  AND  COLLEGE  SANITATION  51 

compel  them  to  tear  out  a  lot  of  antiquated  old  plumbing  and  other  sanitary 
abominations.  A  good  place  to  begin  is  at  the  medical  colleges.  The  aver- 
age medical  institution  houses  several  dead  bodies  "  in  pickle  "  and  in  process 
of  dissection,  beside  numerous  animals  for  experiment,  and  an  odoriferous 
chemical  laboratory,  all  under  the  same  roof  with  lecture  rooms  and  some- 
times a  public  dispensary.  Such  a  conglomeration  should  not  be  permitted. 
The  anatomical  and  pathological  laboratories  should  be  compelled  by  law 
to  be  separately  housed. 

The  tobacco  problem. —  Some  reference  is  made  to  this  in  the  chapter 
upon  pure  food  and  drugs.  It  is  commonly  agreed  that  tobacco  is  dangerous 
to  the  growing  youth,  and  the  data  is  so  extensive  and  the  series  of  com- 
parative tests  so  numerous  that  we  can  regard  the  matter  as  settled.  There- 
fore, school  boards  have  a  perfect  right  to  prohibit  its  use,  and  states  to  enact 
laws  against  the  sale  of  tobacco  to  young  persons.  Also  it  is  very  generally 
agreed  that  the  American  cigarette  is  responsible  for  much  of  harm.  The 
majority  of  men  who  smoke  will  decry  the  use  of  the  cigarette,  and  a  large 
proportion  of  cigarette  users  themselves  frankly  admit  their  possibilities  for 
harm.  The  use  of  the  pipe  and  cigar  by  grown  men  is  regarded  in  a  some- 
what different  light.  While  many  able  scientists  strenuously  oppose  this 
latter  use  of  the  drug,  the  majority  of  men  of  all  shades  of  opinion  in  other 
things  look  upon  the  use  of  the  pipe  and  cigar  by  adult  males  as  a  pastime  and 
mild  habit  of  small  moment  with  the  aggregate  of  men,  but  deleterious  in  the 
case  of  a  small  minority.  Just  what  is  the  scientific  point  of  view  is  hard  to 
define,  since  there  is  but  little  agreement  as  regards  the  points  most  at  issue. 

From  an  examination  of  fourteen  brands  of  smoking  tobacco  I  was 
forced  to  the  conclusion  that  there  is  much  adulteration  and  very  probably  a 
degree  oi  harmful  adulteration  sufficient  to  make  it  very  difficult  to  judge  of  the 
questions  at  issue  until  after  the  chemists  and  others  have  determined  very 
definitely  the  degree  and  character  of  deleterious  adulteration  in  smoking 
tobaccos.  It  is  alleged  that  certain  intoxicating  weeds  are  used  to  adulterate 
tobacco  in  the  United  States.  If  this  be  true,  it  is  difficult  to  say  how  much 
harm  comes  from  the  tobacco  and  how  much  from  the  adulterant.  Further- 
more, it  is  a  matter  of  some  considerable  importance  to  determine  these 
things  specifically  and  without  prejudice. 

The  hygiene  of  athletic  sports. —  Upon  my  desk  lies  a  pile  of  reprints 
upon  certain  phases  of  athletic  sport.  Some  of  them  dwell  upon  the  dangers 
and  others  upon  the  advantages  to  be  derived.  The  place  of  physical  training 
in  a  school  system  has  never  been  accurately  defined.  That  it  has  a  place 
does  not  admit  of  doubt.  So  has  Greek.  How  much  of  a  place  either  one 
should  occupy  in  the  affairs  of  any  specific  young  man  can  best  be  deter- 
mined by  his  personal  equation,  his  balance  as  to  mentality  upon  one  side 
and  the  physical  ego  upon  the  other,  his  environment  and  its  influence  upon 
him,  and  his  own  personal  taste  in  the  matter.  It  is  like  diet:  "  One  man's 
meat  is  another  man's  poison."  No  set  rules  can  be  made.  Systems 
must  be  flexible  and  differing  schools  as  to  the  glorification  of  or  debasements 


52  HYGIENE 

of  the  flesh  must  learn  to  be  amiable  with  one  another's  pet  theories  or  de- 
lusions. Both  the  Samson  and  the  Saint  may  live  long  and  be  happy,  each 
in  his  way. 

Probably  athletics  is  too  much  indulged  while  in  college  and  too  much 
neglected  after  one  is  out.  If  the  French  one  learns  in  the  classroom  be 
kept  up  in  after  years,  it  is  a  real  advantage;  so  with  athletics  and  the  use 
made  of  it  after  school  days  have  merged  into  those  of  business.  Our  English 
and  Canadian  friends  can  teach  us  a  bit  about  such  things.  Parks  are  not 
meant  merely  for  the  youth;  they  are  the  playgrounds  of  the  people.  Some 
day  some  good  citizen  and  wise  man  will  invent  some  good  outdoor  American 
game  suited  for  the  average  adult  and  one  that  does  not  require  a  uniform. 
Athletic  sports  in  college  should  be  regarded  as  a  part  of  the  serious  work 
there  to  rationally  build  up  a  healthy  body  that  should  stay  healthy  so  long 
as  the  mind  is  active  enough  to  demand  muscular  activity.  To  keep  up 
mental  exercise  is  regarded  as  necessary  all  through  life,  but  we  do  not  feel 
the  same  way  about  the  body.     One  is  just  as  necessary  as  is  the  other. 

Sexual  and  venereal  instruction. —  The  trouble  with  this  whole  matter 
has  been  that  no  one  seems  to  want  to  discover  what  is  proper  and  normal 
in  this  phase  of  life.  We  have  theories,  pretty  or  nasty,  according  to  the  way 
one  chooses  to  look  at  them,  and  we  fit  in  the  facts  to  the  theory,  while  the 
other  chap  with  a  different  view  is  standing  at  the  end  of  our  house  of  cards 
ready  to  push  it  over  so  soon  as  he  decides  to  make  a  new  shuffle  to  fit  his 
theory.  The  whole  maze  of  sex  question  literary  pyrotechnics  that  have 
risen  like  rockets  and  come  down  like  sticks  the  last  few  years  have  left  nothing 
but  smoke  behind.  The  sexual  problem  never  became  a  problem  until  man 
begun  to  speak  in  whispers  about  it.  Neither  did  clothes.  It  is  the  trim- 
mings of  both  that  have  made  most  of  the  trouble.  Men  and  women  should 
fit  into  the  general  scheme  of  things  here  just  like  they  did  from  the  beginning 
of  time.  Leave  them  more  to  their  own  natural  instincts  and  morality  will 
be  as  natural  as  is  love  and  usually  the  mating  will  be  for  life. 

While  it  is  certainly  not  the  thing  for  the  small  child,  puberty  should 
mark  the  time  of  supplying  the  information  nature  rules  is  due.  College 
should  advance  the  information  to  a  more  scientific  status  and  the  pathology 
of  sexual  force  may  be  clearly  defined.  The  average  college  student  wants 
to  be  clean.  Most  physicians  have  no  sympathy  with  the  view  that  young 
men  are  all  naturally  unmoral.  The  history  of  the  race  does  not  read  that 
way.  After  all,  there  are  but  two  ways  to  live  the  sexual  life:  that  of  the 
orient,  with  its  polygamy  and  debasement  of  woman,  and  thatofthe  Occident, 
with  legal  wedlock  and  woman  elevated.  You  cannot  mix  the  two.  The 
nations  who  tried  it  in  the  past  went  down  to  oblivion.  The  same  rule  would 
apply  to  us.  Instructing  young  men  upon  the  matter  should  not  consist  of 
explanations  of  the  many  forms  of  legalized  vice  and  prostitution,  but  rather 
telling  them  of  the  inexorable  laws  of  nature  and  the  laws  of  the  land.  There 
need  be  nothing  mystical  about  the  matter,  and  we  can  well  omit  the  wretched 
and  sordid  details  of  the  experiments  with  pathologic  love  that  man  has  been 
fool  enough  to  try  out  in  certain  communities  and  by  means  of  certain  cults. 


SCHOOL  INSPECTION  AND  COLLEGE  SANITATION  53 

College  traininv  in  sanitation. —  Within  the  last  few  months  several 
American  colleges  and  universities  have  announced  courses  preparing  the 
graduate  more  or  less  fully  for  public  health  work  and  administration. 
Among  the  first  to  do  so  was  Cornell.  Regarding  the  work  there  the  Twenty- 
ninth  Annual  Report  of  the  New  York  State  Department  of  Health  gave  a 
syllabus  of  the  lectures,  the  main  subjects  of  which  are  reproduced,  and  com- 
mented upon  the  course,  as  will  be  immediately  quoted.  It  must  be  explained, 
however,  that  these  comments  were  made  before  other  colleges  followed  the 
example  of  Cornell.  Doubtless  many  institutions  will  soon  offer  very  thor- 
ough training  along  the  lines  indicated  in  the  rather  tentative  courses  thus  far 
announced. 


SCHOOL  OF  SANITARY  SCIENCE  AND  PUBLIC  HEALTH 

If  the  public  health  is  to  be  properly  safeguarded  we  must  have  men  rightly 
taught  and  trained  to  do  the  work.  We  need  to-day  expert  sanitarians.  They  must 
be  men  so  instructed  that  they  have  gained  that  comprehensive  grasp  that  gives  a 
mastery  of  the  broader  economic  and  social  problems  of  our  modern  and  complex 
life.  As  so  forcibly  and  clearly  stated  by  Dr.  Ditman,  such  men  should  not  only  be 
able  to  cure  but  should  be  able  to  prevent  disease;  should  be  familiar  with  methods 
of  public  health  administration  which  bear  on  the  purity  of  food  and  water  supplies, 
dangerous  occupations  and  the  occurrence  of  epidemics;  they  should  know  thoroughly 
such  sociological  questions  as  concern  the  habits  of  the  people  and  the  evils  of  tene- 
ment house  existence.  Many  other  matters  should  come  within  their  province. 
They  should  know  the  work  of  the  various  charitable  organizations,  be  conversant 
with  the  different  phases  of  educational  questions,  and  be  able  to  at  all  times  carry  on 
a  continual  campaign  of  education  on  sanitation  among  the  people.  The  need  of  such 
men  is  painfully  apparent,  and  there  are  few  to  be  found.  It  must  be  stated,  although 
not  very  gratifying  to  our  pride,  that  there  is  at  present  no  place  in  these  United  States 
where  such  training  as  that  described  above  may  be  obtained. 

Other  countries  have  outstripped  us  in  the  work,  seeing  clearly  the  absolute 
necessity  of  putting  trained  men  in  charge  of  the  public  health.  In  England,  for 
example,  since  1892,  in  any  country  district  or  combination  of  districts,  no  one  could  be 
appointed  medical  officer  of  health  unless  he  were  a  full  graduate  of  medicine  and 
registered  as  a  holder  of  a  diploma  from  some  university  body  giving  instruction  in 
sanitary  science,  public  health,  or  state  medicine.  This  act  demanded  special  training, 
and  created  a  trained  body  of  medical  state  officers. 

The  urgent  need  of  some  place  where  such  special  training  and  teaching  could 
be  given  caused  the  department  of  health,  with  the  cordial  co-operation  of  the  authori- 
ties of  Cornell  University,  to  establish  at  that  institution  a  fairly  complete  course  in 
sanitary  science  and  public  health.  Its  success  was  marked  from  the  first  lecture. 
The  interest  taken  by  the  students  was  unmistakable,  and  at  times  the  large  hall  was 
unable  to  accommodate  all  who  came.  Since  the  inauguration  of  this  course  the 
movement  has  spread,  and  in  several  institutions  and  colleges  similar  courses  of 
instruction  are  given.  The  experiment,  if  it  could  be  so  termed  at  Cornell,  has 
demonstrated  that  a  school  of  sanitary  science  and  public  health  is  an  imperative 
necessity,  and  it  is  the  plain  duty  of  the  state  to  provide  such  a  school.  A  very  modest 
amount  of  money  would  establish  at  Cornell  in  a  permanent  way  a  school  of  state 
medicine  that  would  return  promptly  a  thousand  fold  its  cost. 


54  HYGIENE 

The  subjects  covered  at  Cornell  were  (1908)  as  follows:  Public  health 
administration.  Town  planning.  Problems  of  life  and  health  in  industry. 
The  relation  of  the  state  to  the  health  of  rural  communities.  The  influence 
of  the  action  of  the  laws  of  heredity  upon  public  health.  Social  problems  in 
their  relation  to  the  public  health.  The  public  health  law.  The  various 
aspects  of  vital  statistics.  Prophylaxis  as  a  public  asset.  Insanity  and  public 
health.  Voluntary  organization  in  public  health  work.  Bacteriology  and 
comparative  epidemiology.  Disinfection  in  its  relation  to  public  health. 
Cancer  in  its  relation  to  public  health.  Food  adulterations  and  their  detec- 
tion. Effect  of  dairy  processes  on  pathogenic  bacteria  and  their  transmission 
to  human  beings.  Dairy  hygiene.  The  need  of  more  attention  to  health  in 
the  public  schools.  Statistics  relating  to  early  tuberculosis.  Waste  of 
wealth  in  New  York  from  preventable  illness  and  death.  Local  quarantine 
measures.  Relation  of  alcohol  to  the  public  health.  Insects  and  the  trans- 
mission of  disease.  The  medical  side  of  the  negro  problem.  The  history 
of  therapeutics.  The  value  of  animal  wastes  in  agricultural  processes.  The 
betterment  of  agricultural  conditions.  Transmission  and  prevention  of  some 
infectious  diseases.  Immunity.  The  law  of  nuisances  and  its  relation  to 
public  health.  Sanitary  science.  Water  filtration.  Water  purification. 
Principles  of  sewage  purification.  Sewage  disposal.  Limnology.  Occu- 
pational diseases  and  their  prevention.  Modern  housing.  Heating  and 
ventilation.     Agricultural  economics.     General  municipal  sanitation. 

Nurses'  Training  Schools. —  There  need  be  very  little  apprehension 
about  the  trained  nurse.  There  are  so  many  grades  of  work  for  the  nurses 
to  do  that  most  of  the  objections  raised  against  them  apply  to  but  a  portion 
of  the  guild,  and  varying  grades  of  nurses  are  needed  for  differing  lines  of 
work.  Certainly  it  is  not  to  be  wondered  at  that  the  really  trained  nurses 
want  to  raise  distinctions  between  themselves  and  those  who  are  notadequately 
trained  for  surgical  and  difficult  work,  but  who  are  admittedly  useful  in  illness 
not  requiring  so  many  detailed  attentions  upon  the  part  of  the  nurse. 

Many  states  have  laws  regulating  the  registration  of  trained  nurses  and 
providing  for  boards  and  examiners,  but  ver}'  few  state  boards  of  health  have 
undertaken  to  define  what  a  nurse  must  know.  The  state  of  Iowa  is  an  ex- 
ception in  this  regard,  and  it  may  not  be  amiss  to  reproduce  these  require- 
iments  of  the  Iowa  State  Board  of  Health. 

NOTICE  TO  SUPERINTENDENTS  OF  TRAINING  SCHOOLS 

In  accordance  with  the  provisions  of  Chapter  139,  Acts  of  the  Thirty-second 
General  Assembly,  the  Iowa  State  Board  of  Health  has  formulated  and  adopted  the 
following  schedule  of  minimum  requirements  for  training  schools  and  admission 
thereto.  This  schedule  will  ake  effect  and  be  in  force  on  and  after  February  1,  1908. 
After  February  1,  1908,  no  training  school  will  be  regarded  as  in  good  standing  by  the 
Iowa  State  Board  of  Health,  unless  such  school  conforms  to  the  minimum  require- 
ments herein  prescribed;  nor  will  the  graduates  of  such  institutions  receiving  their 
diplomas  subsequent  to  February  1,  1908,  be  admitted  to  examination  as  applicants 
for  a  state  certificate  of  registration. 


SCHOOL  INSPECTION  AND  COLLEGE  SANITATION  55 

CONDITIONS  FOR  ADMISSION  TO  TRAINING  SCHOOLS 

All  applicants  for  admission  to  training  schools  for  registered  nurses  must  file 
credentials  as  follows: 

1st.     Satisfactory  evidence  of  good  moral  character. 

2d.  A  certificate  showing  completion  of  grammar  school  course  (after  July  1, 
1910,  a  high  school  course  will  be  required),  or  in  the  absence  of  such  certificate  the 
applicant  shall  pass  a  satisfactory  examination  equivalent  thereto,  such  examination 
to  be  conducted  under  the  supervision  of  the  principal  of  an  accredited  high  school. 
An  applicant  failing  in  one  or  more  branches  in  such  examination  may  be  conditioned 
for  one  year,  at  which  time  such  deficiency  must  be  removed. 

REQUIREMENTS  FOR  TRAINING  SCHOOLS 

To  obtain  recognition  by  this  board,  training  schools  shall  conform  to  the  following 
requirements: 

1st.  They  shall  require  their  matriculates  to  comply  with  the  preliminary  re- 
quirements prescribed  by  this  board,  and  keep  an  accurate  record  of  each  student's 
credentials. 

2d.  The  training  schools  must  be  connected  with  a  general  or  state  hospital 
(or  sanitorium)  having  not  less  than  twenty-five  beds,  and  the  number  of  beds  must 
be  at  least  twice  the  number  of  students  in  the  school,  depending  on  the  character  of 
the  hospital  facilities,  with  private  or  ward  practice. 

SPECIAL  OR  STATE  HOSPITAL  TRAINING  SCHOOLS 

Graduates  of  training  schools  connected  with  a  special  or  state  hospital  will 
be  admitted  to  examination  by  this  board,  only  upon  satisfactory  evidence  of  having 
completed  a  course  of  six  months'  instruction  in  the  general  hospital  of  a  training 
school  of  recognized  standing  with  this  board.  Said  course  may  be  taken  during  the 
last  six  months  preceding  graduation,  or  within  one  year  subsequent  thereto. 

BRANCHES  TO  BE  TAUGHT 

The  following  branches  must  be  taught  by  all  training  schools.  (1)  Elementary 
Anatomy.  (2)  Elementary  Physiology.  (3)  Elementary  Bacteriology  and  Pa- 
thology. (4)  Elementary  Materia  Medica  and  Elementary  Toxicology.  (5)  Ele- 
mentary Hygiene.  (6)  Dietetics,  Domestic  Science,  and  Food  Values.  (7)  Practical 
Nursing.  (8)  Surgical  Nursing,  including  Gynecology,  and  the  eye  and  ear.  (9) 
Medical  Nursing,  including  nervous  diseases  and  contagious  diseases.  (10)  Nursing 
in  children's  diseases.  (11)  Obstetrical  Nursing  and  practical  experience  in  at  least 
six  cases.  (12)  Chemistry  and  Urinary  Analysis,  (13)  Medical  Jurisprudence. 
(14)  Nursing  of  diseases  peculiar  to  men  for  men. 

Note. —  The  state  examination  will  include  also  the  rules  and  regulations  of 
the  Iowa  State  Board  of  Health  relating  to  infectious  and  contagious  diseases  and 
quarantine. 

PERIOD  OF  TRAINING 

The  period  of  instruction  in  the  training  school  shall  be  not  less  than  two  (2)  full 
years  (three  (3)  years  being  recommended).  Training  schools  having  a  three  years' 
course,  and  wishing  to  send  pupils  outside  the  hospital  in  private  cases,  may  pursue 


56  HYGIENE 

this  practice  only  during  the  student's  senior  year;  but  said  outside  work  shall  not 
exceed  three  months  of  the  course.  Training  schools  having  only  a  two  (2)  years' 
course  will  not  be  accorded  this  privilege  unless  they  extend  the  course  to  three  (3) 
years. 

After  July  1,  1910,  no  training  school  will  be  in  good  standing  with  this  board 
which  does  not  require  a  three  (3)  years'  course  of  study.  It  is  earnestly  recommended 
that  all  training  schools  forthwith  adopt  a  three  (3)  year  course. 

SCHEDULE  OF  SUBJECTS 

The  following  schedute  of  subjects,  together  with  the  number  of  hours  to  be 
taught  in  each  branch,  is  recommended  by  the  board;  a  rearrangement  of  the  several 
branches,  however,  may  be  made  to  meet  local  conditions: 

FIRST  YEAR 

Anatomy       15  hours 

Hydrotherapy 5 

Practical  nursing,  including  massage 40 

Physiology .  15 

Hygiene 5 

Domestic  science  (including  dietetics  and  cookery, —  food  values)  20 

Chemistry  and  urinary  analysis 5 

Physical  culture 10 

El.  bacteriology  and  pathology    10 

125  hours 
SECOND  YEAR 

Medical  nursing,  including  nervous  diseases,  contagious  diseases, 
and  the  Rules  and  Regulations  of  the  Iowa  State  Board  of 

Health  relating  to  infectious  diseases  and  quarantine 36  hours 

Practical  nursing    18    j 

Children's  diseases 15 

Obstetrical  nursing  and  obstetrics 10 

Materia  medica  and  toxicology 10 

Surgical  nursing,  including  eye  and  ear  and  gynecology 30 

Preparation  of  food  for  sick 20 

Nursing  ethics    3 

142  hours 
THIRD  YEAR 

Medical  nursing,  including  nervous    diseases    and    contagious 

diseases    20  hours 

Surgical  nursing,  including  eye  and  ear  and  gynecology 20 

Electro-therapeutics 5 

Medical  jurisprudence 5 

Nursing  ethics 3 

Review 50 

Emergencies 15 

118  hours 


SCHOOL  INSPECTION  AND  COLLEGE  SANITATION  57 

Training  schools  maintaining  only  a  two-year  course  must  arrange  their  schedule 
so  as  to  cover  the  work  outlined  in  the  foregoing  requirements. 

The  foregoing  rules  were  adopted  by  the  Iowa  State  Board  of  Health  on  January 
22,  1908,  and  are  in  full  force  and  effect  on  and  after  February  1,  1908. 

(Attest:)  Louis  A.  Thomas,  (Signed:)  J.  H.  Sams, 

Secretary  President 

One  reads  much  of  the  nurses  knowing  too  much  about  therapeutics. 
I  instruct  a  class  of  nurses  in  materia  medica  and  therapeutics  and  find  it 
hard  to  drill  the  subject  into  them  and  they  complain  of  the  difficulties. 
Therefore,  it  does  not  appear  to  me  that  they  are  very  apt  to  undertake  the 
administration  of  any  but  emergency  remedies.  It  is  in  such  drugs  and  anti- 
septics that  I  give  most  drill. 

The  trained  nurse  has  hardly  gotten  her  bearings  as  yet,  but  it  does  not 
appear  to  me  that  the  outlook  is  at  all  bad.  Certainly  they  have  a  well- 
defined  place,  not  only  in  the  care  of  patients,  but  also  in  certain  matters  of 
public  health. 


Chapter  IV 
PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE 

The  bad  record  of  the  past  as  regards  jails  —  Some  present  bad  conditions. 
Signs  of  improvement  —  Speciahzing  in  correction  —  Plans  tending  toward  a  more 
rational  treatment  of  crime  and  criminals  —  Some  instances  of  correct  practice  — 
Disease  in  prisons  —  The  special  hygiene  of  large  prisons  —  Of  smaller  prisons  —  The 
tramp  question  —  Juvenile  offenders — The  medical  service  of  prisons  —  Infectious 
■diseases — Some  general  considerations. 

The  Police. —  Their  services  to  the  public  —  Police  ambulances  —  The 
police  matron  —  The  sanitary  police  —  Their  place  in  suppressing  vice  —  Police 
instruction  in  first  aid  —  Their  future. 

Insanity  and  its  care  in  the  broader  aspects  of  prevention,  the  hygiene  of  insti- 
tutions and  the  general  care  of  perversions  and  moral  conditions  due  to  insanity. 


AND  this  conjuration  and  mighty  magic  that  worked  so  great  a  transformation 
when  the  most  ingenious  punishments  had  failed  of  effect  is  the  new  spirit 
that  is  beginning  to  appear  in  the  conduct  of  our  prisons.  Prisons  are  terrible 
things,  and  of  rather  more  than  doubtful  utility;  and  yet  I  know  of  nothing  that 
gives  one  stronger  hope  than  to  contemplate  their  history. 

How  long  ago  were  men  thrown  into  such  frightful  dungeons  as  the  cells  under 
the  canals  at  Venice  ?  How  long  ago  were  the  days  of  branding  and  ear-splitting  ? 
When  did  lashing  at  the  cart  tail  cease,  and  those  mad  processions  of  Tyburn  ?  How 
long  ago  was  the  Bastile  merely  a  type  of  a  hundred  European  prisons,  no  better  and 
no  worse  ?  How  many  thousand  wretches  actually  rotted  away  in  such  filthy  dens  ? 
How  about  prison  fever  and  the  death  rate  that  used  to  be  appalling  when  prisons 
were  unventilated  and  without  a  pretense  at  sanitation  ?  How  about  the  prison 
hulks  that  not  so  very  long  ago  cursed  the  harbors  of  England  \  How  about  the 
system  of  transporting  felons  over  seas,  which  lasted  until  almost  the  present  genera- 
tion ?  How  about  the  sickening  and  hellish  horrors  of  Botany  Bay  and  Norfolk 
Island  ?  What  was  written  of  Newgate  sixty  years  ago  ?  What  were  the  English 
prisons  like  in  the  days  of  Charles  Reade  ?  And  so  we  come  up  the  long  trail  of  mani- 
fold horrors,  cruelties,  and  barbarisms,  burnings,  manglings,  beatings,  from  the 
dungeons  of  France  before  the  Revolution,  past  the  American  commonwealth  that 
still  maintains  the  whipping  post,  to  the  decency,  cleanliness,  and  human  impulses 
-displayed  at  Fort  Leavenworth  or  Joliet,  up  at  last  to  a  prison  system  like  that  of 
New  Zealand  that  has  no  thought  of  breaking  the  fallen  man's  spirits  nor  of  exacting 
retribution,  but  only  of  restoring  him  whole  to  his  due  place  among  his  fellowmen. 

Along  this  road,  in  spite  of  the  survival  of  some  of  the  vilest  prisons  in  the  world, 
and  in  spite  of  the  unspeakable  horrors  of  the  Southern  convict  camp,  we  make 
•progress.     Not  very  swift,  but  still  progress. 

This  quotation  is  from  a  series  of  articles  by  Charles  Edw^ard  Russell, 
upon  American  prisons,  and  is  running  in  Hampton's  Magazine,  beginning 
in  the  number  for  September,  1909.  To  Mr.  Russell  and  other  able  writers  I 
am  indebted  for  some  of  the  data  used  in  this  chapter,  v^^hile  the  rest  is  from 
my  own  observation  and  the  photographs  used  were  taken  by  myself. 

Prison  reform  is  a  large  subject,  and  it  would  give  me  much  pleasure 
to  detail  what  has  been  done  by  the  large-hearted  people  who  have  awakened 


PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE      59 

to  the  cry  of  the  prisoner.  My  observation  and  reading  have  convinced  me  of 
two  things.  The  first  can  be  illustrated  by  giving  the  reply  of  an  able  judge 
when  asked  why  his  sentences  were  usually  for  such  short  terms;  he  said, 
"  Most  prisons  punish  a  man  beyond  what  the  law  designs."  This  has  been 
literally  true  and  is  true  of  many  of  them  to-day.  Certain  it  is  that  the  passing 
of  sentence  ends  the  jurisdiction  of  the  court  and  the  convicted  man  passes 
from  the  scrutiny  of  a  learned  profession  and  an  able  court  to  the  care  of  a  set 
of  officials  who  may  be  merciful  and  just,  but  who  in  the  past  seldom  were 
either  and  may  yet  be  selected  by  political  considerations  in  which  neither 
mercy  nor  justice  have  a  part.  But  this  is  a  day  of  publicity,  and  the  cloister 
and  solitary  dungeon  have  no  part  in  modern  civilization.  Whether  the 
end  be  religion  or  punishment,  it  is  contrary  to  human  nature  and  divine 
requirements  that  man  be  shut  up  alone  to  his  own  thoughts  and  the  morbid 
introspection  that  ferments  in  the  darkness  and  turns  to  acid  all  the  sweetness 
that  God  placed  in  the  human  mind  and  heart. 

And  this  leads  to  the  second  thing,  and  that  is  that  public  policy  has  ever 
been  largely  dominated  by  the  preconceived  ideas  man  forms  of  divine  policy. 
The  frightful  theological  nightmares  of  the  past  were  responsible  for  much 
of  law  that  was  cruel  and  for  much  of  war  that  was  hell.  Read  history,  and 
my  statement  needs  no  comment. 

A  theological  course  taught  me  that  the  original  Greek  and  Hebrew 
Scriptures  have  been  so  warped  and  twisted  in  the  course  of  ages  and  eccle- 
siastical wrangling  in  trying  to  frighten  men  into  the  faith,  that  the  legalistic 
idea  of  God  and  His  dealings  with  men  have  darkened  the  light  of  the  gospel, 
and  the  humanitarianism  of  Jesus  Christ  has  been  kept  In  the  background, 
until  men  who  were  not  ecclesiastics  were  forced  to  accept  either  rationalism 
or  to  restudy  the  ancient  Scriptures  in  the  light  of  modern  scholarship.  This 
has  been  done,  and  is  the  most  hopeful  aspect  of  Christianity  to-day.  Prob- 
ably an  awakening  in  many  things  was  due  for  this  age,  but  it  is  certainly 
significant  that  a  better  understanding  of  God  is  leading  men  to  a  better 
understanding  of  each  other.  The  horrors  of  war,  the  blaming  of  disease 
upon  Divine  Providence,  racial  antagonism,  human  slavery,  the  degradation 
of  woman,  enslaving  our  fellows  with  alcohol  and  degrading  drug  habits,  and 
the  cruelties  of  prison  life  are  all  things  that  men  are  coming  to  see  in  a  new 
light  bred  of  true  perspective  and  the  light  of  a  cleansed  religion.  We  doc- 
tors are  apt  to  feel  aggrieved  when  religions  invade  the  field  of  therapy.  Let 
us  give  to  religion  the  proportion  of  credit  due  In  preparing  men's  minds  for 
better  conditions  In  all  things  inclusive  of  preventive  medicine. 

The  bad  jails  of  the  past. —  The  saddest  sight  I  have  ever  seen,  next  to 
the  great  disaster  at  Johnstown  after  the  excitement  was  over,  or  a  railroad 
wreck  in  which  I  saw  people  burning  to  death,  was  at  a  big  penitentiary  of  the 
old  political  type  and  in  which  the  poor  victims  of  the  brutal  contract  system 
were  kept  at  work  with  rifles  always  pointing  at  them.  That  punishment 
by  brutal  flogging,  by  confinement  in  absolute  darkness,  by  strangling  with 
the  fiendish  "  water  cure,"  by  being  strung  up  in  the  "  bullrings,"  the  elec- 


60 


HYGIENE 


A  dark  prison  of  the  old  and  insanitary  type 

trie  torture  of  the  "  hummingbird  "  and  other  more  refined  but  not  less 
barbarous  means  need  not  be  denied  by  officials  in  the  face  of  overwhelming 
proof  of  the  fact. 

The  disreputable  old  dungeon  shown  on  this  page  was  a  fair  type  of  what 
the  average  state  penitentiary  was  like  not  so  many  years  ago.  In  fact,  some  of 
them  look  like  it  now.  In  dark  prisons  like  this  sanitation  is  almost  unknown 
in  any  but  the  old  prison  sense.  Men  are  packed  away  like  sardines  and 
doomed  to  all  but  certain  tuberculosis. 

The  literature  and  the  affidavits  in  proof  of  such  cruelty  is  so  extensive 
that  we  need  not  harrow  the  reader's  soul  by  reproducing  it  here.  Fortu- 
nately, most  of  that  sort  of  thing  is  done  within  this  country,  although  there 
are  prisons  in  which  it  is  stated  that  such  measures  survive.  I  have  no  per- 
sonal knowledge  of  any  such  places  existing  now,  although  there  is  reason  to 


PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE       61 

believe  that  there  must  be  at  least  some  truth  in  statements  discharged   pri- 
soners make  about  present  cruelty. 

In  taking  occasion  to  interview  gentlemen  identified  with  corrections,  I 
find  them  alert  to  advances  made.  Many  of  them  are  broad  gauge  gentle- 
men and  do  not  think,  as  some  persons  state,  that  "  the  prison  reform  cranks 
are  wild-eyed  fanatics."  As  a  matter  of  fact,  some  of  the  latter  are  better 
informed  about  prison  management  than  are  the  class  of  wardens  who  never 
see  anything  of  prisons  except  their  own  institutions.  On  the  other  hand,  the 
reform  people  do  number  among  them  some  very  theoretical  persons  who 
do  not  realize  what  a  tough  proposition  is  the  confirmed  criminal. 

Signs  of  unprovement. —  These  are  almost  universal.  The  federal  gov- 
ernment has  probably  been  in  the  fore  in  the  matter.  "  The  Turn  of  the 
Balance,"  by  Brand  Whitlock,  tells  what  has  been,  and  the  balance  is  turning 
in  the  right  direction.  No  longer  does  the  official  who  has  informed  himself 
by  study  of  conditions  and  by  travel,  consider  it  well  to  "  break  the  spirit  of 
the  prisoner  "  ;  he  does  not  consider  that  brutality  really  ever  reformed  any 
man;  that  the  medieval  idea  of  revenge  is  creditable  to  a  state;  that  stripes 
upon  clothing  removes  the  leopard's  stripes;  that  lock-step  discipline  is  of 
any  value;  that  shaving  the  head  improves  the  conduct  of  a  felon,  or  that  the 
convict  leasing  system  has  one  redeeming  feature.  We  wish  we  had  the 
space  to  give  details  as  to  actual  results  from  the  newer  ideas  in  correction. 
It  is  a  fact,  that  with  the  great  majority  of  prisoners  the  new  methods  result 
in  better  discipline  in  the  prison,  vastly  less  disease  and  a  very  greatly  increased 
proportion  of  men  and  women  whose  reform  is  testified  to  by  the  fact  that  they 
have  no  future  criminal  history.  They  leave  the  prison  better  citizens  than 
when  they  entered.  This  can  be  said  of  very  few  under  the  old  system.  Un- 
fortunately, it  must  be  admitted  that  there  is  a  certain  proportion  of  hardened 
criminal  upon  whom  the  new  system  seems  to  be  wasted. 

It  is  strange  how  one  sees  the  good  and  bad  side  by  side.  The  state  of 
Kansas  has  a  penitentiary  that  is  said  by  Mr.  Russell  to  be  a  disgrace  to  the 
state,  and  it  also  has  within  its  borders  the  Fort  Leavenworth  Federal  Peni- 
tentiary, one  of  the  most  humane  in  the  world  and  a  model  in  its  way.  Miss 
Kate  Barnard,  the  State  Commissioner  of  Charities  of  Oklahoma,  is  a  won- 
derful instance  of  what  a  woman  can  do  in  public  life.  I  have  read  her 
biography,  and  it  should  be  an  inspiration  to  every  woman  who  enters  public 
work.  She  has  shown  up  the  bad  penitentiary  in  Kansas  in  a  way  to  make 
one's  blood  run  cold.  If  you  don't  believe  her,  ask  Oklahoma.  She  is  a 
power  out  there  and  the  state  is  proud  of  her. 

The  warden  at  Fort  Leavenworth,  Maj.  R.  W.  McClaughry,  believes  that 
outdoor  work  is  the  solution  of  most  of  the  prison  problems.  The  convicts 
there,  and  there  are  some  very  bad  ones,  erected  nearly  everything  upon  the 
place  and  the  plans  were  such  that  sanitation  was  first  of  all. 

Mr.  Russell  says  of  this  prison: 

You  may  probably  observe  here  that  a  great  increase  of  mental  and  moral,  as 
well  as  of  physical  health  is  found  to  follow  outdoor  work  for  convicts.  At  Fort 
Leavenworth  the  men  that  work  out  of  doors  give  practically  no  trouble.     Fifty 


62  HYGIENE 

convicts  often  work  on  the  farm  in  charge  of  only  two  guards,  and  no  attempt  at  escape 
has  been  reported  in  this  squad.  This  reminds  me  that  in  New  Zealand  I  have  seen 
forty  convicts  working  in  the  woods  many  miles  from  the  prison  and  guarded  by  one 
keeper,  armed  with  a  walking  stick.  None  of  them  ever  seemed  to  want  to  run  away. 
It  must  be  wise  to  theorize  about  the  necessity  for  force,  guns,  and  spirit  breakers, 
or  we  should  not  have  so  much  of  such  arguing;  but  as  a  matter  of  practice,  good 
will,  decency,  and  kindness  seem  much  more  effective  in  keeping  men  in  order. 

Later  in  his  argument  he  says: 

Fort  Leavenworth  is  not  cursed  with  politics;  therefore  it  can  be  operated  by  men 
that  understand  penolog}',  and  have  higher  ideals  than  to  get  and  keep  a  "  job."  Stripes 
are  abolished,  the  convicts  wear  an  attractive  dark  gray  uniform.  Corporal  punish- 
ment is  unknown.  The  food  is  good,  sufficient,  and  well  cooked.  The  kitchens  are 
marvelous  places,  where  cooking  is  done  with  steam  in  great  polished  copper  caldrons. 
Meals  are  served  bv  colored  waiters  wearing  neat  white  aprons  and  white  caps;  fresh 
air  and  light  abound.  Dishes,  table,  and  floor  are  clean,  guards  decent,  and  convicts 
regarded  as  human  beings.     Which  seems  to  be  much  the  best  way. 

To  hasten  on,  Joliet,  Stillwater,  and  other  prisons  in  Minnesota,  Canon 
City,  Michigan  City,  the  prisons  of  New  York  state,  those  of  Michigan,  of 
Massachusetts,  and  isolated  ones  all  over  the  country,  are  tr}'ing  the  newer 
ideas  in  correction  and  the  results  are  good.  A  volume  could  be  written  upon 
the  subject,  but  it  is  to  be  hoped  that  prison  physicians  who  may  read  this 
paper  will  interest  themselves  in  the  subject  and  study  the  matter  in  a  de- 
tailed way  impossible  here,  and  will  use  their  influence  to  better  conditions 
where  defective. 

Specializing  in  correction. —  Any  one  who  takes  the  trouble  to  secure 
and  study  the  prison  reports  of  the  states  and  cities  will  know  that  the  prison 
work  of  this  countr}'  is  rapidly  becoming  a  highly  specialized  profession,  and 
that  many  earnest  people  are  developing  the  different  lines  of  penal  and 
reform  work.  The  subject  is  too  large  to  discuss  here,  but  the  work  along 
special  reform  lines  is  not  only  most  interesting,  but  promises  in  time  to  render 
the  prison  population  of  the  country  a  smaller  proportion  of  the  whole. 

Rational  treatment  of  the  criminal  element. —  This  is  a  question  for  the 
social  settlement  worker,  the  sociologist,  the  criminologist,  the  church  and 
the  sanitarian.  All  should  work  together  tow^ard  a  solution.  Magazine 
articles  galore  treat  the  subject  from  varying  points  of  view.  We  should  read 
these  articles.  The  race  question  enters  in  very  largely  and  the  people  of 
differing  nationality  must  be  handled  differently.  The  prevention  of  crime 
will  bring  better  results,  perhaps,  than  does  the  punishment  of  the  criminal. 
We  spend  large  sums  in  preventive  medicine  and  find  it  pays.  Wh)'  not  pre- 
vent crime  ?  How  about  the  liquor  problem  ?  What  of  immorality  r  What 
influence  does  the  amusements  of  the  people  have  upon  the  crime  question  ? 
The  church  has  long  been  struggling  along  with  the  question,  and  that  the 
churches  are  doing  a  good  work  does  not  admit  of  doubt.  Is  the  church 
alone  strong  enough  to  stem  the  tide  ?  If  not,  who  or  what  should  help  and 
what  part  in  the  general  work  should  the  church  occupy  ?  The  doctors  are 
surely  getting  together  and  are  doing  what  work  in  crime  prevention  relates 


n 

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o 

PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE       63 

to  insanitary  conditions.  The  state  helps  the  doctor  to  do  his  work;  should  it 
help  the  persons  identified  with  the  other  factors  of  the  problem  ?  If  not, 
why  not  ? 

The  engineer  has  dropped  some  academic  theories  and  is  now  serving 
sanitation  and  is  improving  housing  and  industrial  conditions;  the  doctors 
are  dropping  sectarianism  and  are  largely  working  together  for  the  good  of 
the  public  at  large;  the  sociologist  goes  more  to  the  slums  now  than  to  lec- 
tures; the  criminologist  is  dropping  the  theories  of  past  years  and  is  doing  a 
large  work  in  reform;  it  is  now  up  to  the  different  churches  to  drop  the  foolish 
dogmas  to  which  no  one  will  listen  and  join  hands  with  the  rest  of  us  in  a 
great  work. 

Some  instances  of  correct  practice. —  There  could  be  many  given,  but 
because  of  the  prominence  of  New  York  city  I  will  describe  a  few  of  the 
things  to  be  seen  there,  confining  my  remarks  mainly  to  the  sanitary  points 
of  interest.  I  had  the  pleasure  of  meeting  the  Hon.  John  J.  Barry,  Com- 
missioner of  Corrections  of  New  York  city,  at  his  ofltice,  and  he  afforded  me 
every  opportunity  to  inspect  any  or  all  penal  institutions  under  his  jurisdic- 
tion. It  would  unduly  fill  pages  to  describe  all  I  saw,  but  one  cannot  but 
realize  what  a  complex  subject  is  prison  administration  when  you  see  the 
mass  of  detail  incident  to  such  work,  and  talk  with  the  many  people  who  are 
trying  to  bring  about  better  conditions  among  the  criminal  element  in  a  large 
city.  As  I  understand  it,  the  public  and  legislative  bodies  must  be  edu- 
cated in  matters  of  prison  reform  before  appropriations  commensurate  to 
the  needs  of  the  work  will  be  forthcoming.  A  vast  deal  of  newspaper  criticism 
of  prisons  has  a  basis  in  insufficient  appropriations. 

If  there  is  excuse  anywhere  for  crowding  and  for  dark  quarters  justify- 
ing the  term  heading  this  section,  it  is  in  a  "  city  prison,"  the  official  name 
of  this  institution.  Situated  at  Fourth  Avenue  and  Central  Street,  the 
ground  covered  is  very  valuable.  Yet  there  is  a  prison  yard  of  considerable 
size,  a  small  section  being  shown  in  the  photograph.  It  is  clean  and  orderly, 
and  the  prisoners  take  exercise  therein  daily.  Mr.  Wm.  Flynn,  the  warden, 
told  me  there  were  usually  nearly  five  hundred  prisoners  in  the  cells,  and  they 
were  orderly  as  a  rule  and  gave  very  little  trouble.  Parts  of  the  buildings  are 
dark,  but  the  average  prison  in  small  towns  is  not  so  well  lighted  as  is  this 
one,  due  to  the  large  windows,  as  shown  in  the  outside  view  of  a  portion  of  the 
building.  Prisoners  are  carefully  classified  and  the  employes  are  of  a  better 
class  than  one  finds  in  the  average  prison.  Female  prisoners  are  officered 
exclusively  by  matrons. 

The  construction  is  good.  There  is  no  chance  for  vermin  to  be  har- 
bored for  any  length  of  time,  as  the  cells  are  models  of  sanitary  construction 
and  the  iron  beds  and  cell  fixtures  are  regularly  scrubbed.  The  cells  have 
better  plumbing  than  has  the  average  house,  and  ward  shower  baths  are 
supplied.  I  saw  no  rubbish  about  the  place,  or  no  place  needing  paint  or 
reconstruction.  The  sewers  are  flushed  out  with  fire  hose  every  day,  and 
there  was  absolutely  no  suggestion  of  "  the  prison  smell."  The  religious 
care  of  the  prisoners  is  excellent. 


64  HYGIENE 

The  electric  lighting  is  good  and  every  cell  has  its  light.  Little 
hospital  care  is  needed,  seriously  sick  prisoners  being  removed  to  a  proper 
hospital  outside. 

The  food  interested  me  and  I  found  that  it  v^as  good  and  w^ell  cooked. 
The  kitchens  were  models  of  cleanliness.  The  foods  are  furnished  by  strict 
specification  and  no  inferior  or  insanitary  food  is  accepted.  There  are  some 
pretty  hard-looking  prisoners  received,  and  under  the  barbarous  rule  of  some 
prisons  there  would  be  all  kinds  of  trouble  with  them.  While  I  was  there 
visitors  were  coming  and  going,  and  I  intercepted  two  or  three  coming  out 
and  quizzed  them  about  what  they  thought  of  conditions  inside.  The  replies 
evaded  everything  about  the  prison  and  they  seemed  to  have  little  interest 
or  care  about  the  prison  or  the  wellfare  of  their  friends  inside,  but  they  all 
took  occasion  to  narrate  improbable  hard-luck  tales  and  want  the  authori- 
ties or  myself  or  any  one  to  give  them  money  or  supplies  and  "  do  it  quick." 
All  over  the  East  Side  one  finds  the  uppermost  thought  to  be  to  get  something. 
A  very  large  portion  of  the  prisoners  in  this  institution  wanted  to  get  something 
and  the  only  function  of  the  city  administration,  in  the  eyes  of  these  people, 
is  to  give  them  something.  The  women  are  the  worst  of  all,  and  it  is  no 
wonder  their  men  get  into  trouble.  The  American  spirit  of  get,  get,  get  is 
not  confined  to  high  life.  The  recent  structural  troubles  with  "  The  Tombs  " 
are  due  to  the  foundations  of  an  adjoining  building  slipping,  due,  probably, 
to  the  excavations  for  the  subway. 

Blackweir s  Island,  once  a  place  for  political  contractors  to  exploit  at 
the  expense  of  the  poor,  is  now  a  very  interesting  place  to  visit.  The  wretched 
penitentiary  of  the  past  is  going,  and  the  new  is  taking  the  place  as  fast  as  the 
old  can  be  torn  down.  Plans  are  under  way  whereby  the  island  will  be 
turned  into  one  of  the  best  and  most  beautiful  hospital  reservations  in  the 
world.  There  will  be  three  zones,  one  will  be  a  metropolitan  hospital  dis- 
trict, another  for  the  insane,  and  the  third  for  city  hospitals.  The  penal  in- 
stitutions will  be  removed  to  Riker's  Island  and  other  places.  The  New 
York  Penitentiary  is  still  at  the  old  place,  but  the  prisoners  are  kept  busy 
largely  at  work  for  the  improvements  under  way,  and  the  conditions  are  such 
as  to  justify  the  contention  of  Leavenworth,  that  work  is  the  best  thing  for  the 
prisoner.  It  may  be  some  years  before  the  penitentiary  is  wholly  removed. 
The  report  shows  that  the  work  is  largely  outside  labor.  The  workhouse  is 
another  institution  really  in  quite  a  sanitary  condition,  considering  the  fact 
that  some  of  the  buildings  are  old.  Plumbing  and  all  sanitary  arrangements 
are  good,  and  this  institution  is  another  instance  justifying  the  contention  in 
favor  of  work.  The  medical  and  surgical  service  is  excellent,  and  one  can- 
not but  feel  that  the  petty  criminals  have  here  an  excellent  schooling.  A 
detailed  study  of  these  institutions  would  be  interesting  and  the  range  of 
work  done  by  the  prisoners  is  remarkable.  The  new  penitentiary  on  Riker's 
Island  will  be  a  model  institution  with  industrial  and  school  features,  placing 
it  in  the  front  rank,  and  it  will  cost  several  million  dollars.  Note  the  grouping 
of  the  buildings,  and  that  the  light  that  will  reach  the  various  portions  of  the 
place  will  make  it  cheerful.     The  location  is  ideal  and  the  plans  call  for 


PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE       65 

sanitary  arrangements  and  such  surroundings  as  will  make  the  place  a  penal 
health  resort  to  which  to  transfer  prisoners  in  bad  physical  condition. 

The  various  district  prisons  and  the  city  reformatory  complete  a  system 
of  corrections  admirably  striving  to  bring  to  pass  the  best  of  recent  thought  in 
prison  reform.  In  it  all  I  have  been  impressed  with  the  fact  that  education 
and  healthful  work  amid  sanitary  surroundings  remove  the  bad  elements  of 
prison  life.  It  is  true  that  the  element  of  punishment  is  not  lacking,  but  it  is 
so  reasonably  administered  even  with  the  worst  element  of  people  that  it 
will  be  an  object  lesson  to  the  old-time  jailor  to  visit  New  York  city  and  get  a 
permit  to  see  the  workings  of  the  various  prisons.  He  will  see  some  things 
not  yet  ideal,  but  if  he  visits  the  office  of  the  commissioner  and  studies  the 
plans  of  the  department  he  will  see  that  deficiencies  are  being  corrected  as 
fast  as  the  funds  can  be  secured. 

Disease  in  prisons. —  In  the  old  institutions  there  is  more  disease  than 
there  should  be.  Much  of  it  could  be  prevented.  Many  persons  who  reach 
the  prison  are  wrecked  with  alcohol  and  disease,  and  prison  life  is  good  or  bad 
for  them  according  to  the  degree  of  sanitation  and  humanitarianism  of  the 
prison  and  its  administration.  In  a  modern  institution,  many  of  these  phy- 
sical wrecks  end  their  terms  better  physically  and  in  ever}'  other  way  than 
they  were  upon  entrance. 

The  special  hygiene  of  large  prisons. —  Tuberculosis  is  the  special  prob- 
lem here.  Fortunately,  there  is  usually  more  capable  administrators  in  the 
large  institution  than  in  the  small  one.  Sometimes  three  is  a  difficulty  in 
providing  sufficient  work  for  the  large  number  of  inmates.  Some  states 
limit  the  amount  of  work  by  statute.  Probably  these  laws  were  well  meant 
when  enacted,  but  it  is  better  to  leave  such  matters  to  the  prison  management 
than  to  legislate  concerning  them. 

Of  smaller  prisons. —  Some  of  the  small  penitentiaries  and  the  county 
jails  are  abominations.  No  one  seems  to  take  sufficient  interest  in  them  to 
awaken  the  public  to  the  conditions.  Sheriffs  and  wardens  are  so  often 
selected  from  the  small  fry  politicians  that  decorate  the  county  seat  that  the 
prison  "  job  "  is  a  rew^ard  for  political  sers'ices  and  no  real  work  or  interest 
is  expected.  One  cannot  blame  these  officials,  but  it  is  time  the  tax  payers 
of  the  country  took  enough  interest  in  the  prisons  to  select  better  men.  One 
sees  much  of  criticism  of  the  city  politician,  but  for  absolute  littleness  and 
petty  graft  commend  me  to  the  political  contingent  in  the  average  county  seat 
where  politics  is  one  sided.  Many  physicians  could  do  their  counties  a  real 
service  by  making  unexpected  visits  to  the  wretched  jails  usually  found  and 
then  give  them  a  well-deserved  write  up  in  the  local  paper. 

The  tramp  question. —  Several  years  ago  I  took  a  short  tour  with  a  college 
graduate  who  had  turned  "  bum."  It  is  strictly  within  the  truth  when  I  say 
we  had  a  really  good  time,  and  I  would  enjoy  repeating  the  experience.  That 
should  not  be  the  case.  We  have  ourselves  to  blame  for  the  tramp  nuisance. 
People  seem  to  be  afraid  of  them  and  feed  them  for  fear  they  will  set  the 
barns  on  fire.     Enforced  hard  work  is  the  main  solution  and  rural  police  is 


66  HYGIENE 

the  second.  Surely  the  boarding  of  tramps  in  jail  is  an  injustice  to  the  tax 
payer.  On  the  other  hand,  some  honest  men  who  want  work  go  upon  the 
road.  We  need  officials  who  can  differentiate.  I  am  in  favor  of  a  tramp's 
gallery  and  Bertillon  measurements,  as  well  as  a  record  of  the  whole  "  pro- 
fesh."  The  chronic  vagabond  thus  traced  should  be  imprisoned  and  made 
to  work  hard  at  some  form  of  productive  labor  and  turned  out  with  small 
wages  for  his  work.  Then,  if  he  is  picked  up  again,  he  should  be  put  at 
disagreeable  work  upon  a  smaller  wage.  He  is  an  anomaly  and  a  nuisance, 
and  it  is  time  he  be  eliminated  from  the  round  of  comfortable  jails  he  selects. 
Juvenile  offenders. —  I  pity  these  little  chaps.  They  are  more  smned 
against  than  sinning.  Drink,  immorality,  and  criminality  among  parents 
is  the  real  basis  for  most  of  the  youngsters  going  wrong. 

"  Original  sin  "  is  mostly  copied  and  "  innate  depravity  "  is  not  so  uni- 
versal as  most  persons  imagine.  Give  the  youngster  a  chance.  People  who 
make  bad  parents  should  no  more  complain  when  the  society  to  protect 
children  from  cruelty  takes  them  away  than  when  a  similar  society  takes 
away  the  horse  they  beat  and  starve.  Children  are  of  more  value  than  are 
horses. 

The  medical  service  of  prisons. —  There  is  but  one  point  I  care  to  make 
here,  and  that  is  that  the  medical  service  of  a  prison  should  be  a  sanitary 
service  as  well.  The  prison  doctor  should  have  legal  power  to  super\"ise  the 
sanitation  of  the  prison.  The  advantages  are  so  obvious  that  little  discus- 
sion is  needed.  In  many  prisons  this  is  done  and  it  works  out  well,  provided 
the  doctor  studies  sanitation. 

Infectious  diseases. —  The  following  from  the  statutes  of  Virginia  covers 
the  main  points  to  be  observed.  It  is  not  usually  considered  wise  for  a  prison 
to  risk  contagion  within  its  walls  unless  the  grounds  are  large  and  a  proper 
isolation  hospital  can  be  maintained: 

Section  1743a.  Quarantine  for  convicts  in  the  penitentiary  and  prisoners  in  the 
jails  in  case  of  any  contagious  or  infectious  diseases. 

It  shall  be  lawful  for  the  governor  of  the  commonwealth  of  Virginia,  upon  the 
application  of  the  superintendent  of  the  penitentiary,  when  requested  in  writing  so 
to  do  by  the  physician  at  said  institution,  to  have  removed  from  said  penitentiary  any 
felon  or  prisoner  serving  a  term  of  imprisonment  who  has  contracted  any  such  con- 
tagious or  infectious  disease  dangerous  to  the  public  health  to  some  place  to  be  desig- 
nated bv  the  said  governor,  and  when  any  such  prisoner  is  so  removed  he  shall  be 
safely  kept  and  treated  for  said  disease,  and  as  soon  as  he  recovers  his  health,  be 
returned  by  said  superintendent  to  said  penitentiary-,  unless  the  term  of  his  imprison- 
ment has  expired  during  his  quarantine,  in  which  event  he  shall  be  discharged,  but 
not  until  all  danger  of  his  spreading  contagion  has  passed. 

(2)  The  judges  of  the  county  and  corporation  courts  of  the  commonwealth  are 
likewise  authorized  and  empowered  to  have  removed  from  the  jails  of  their  respective 
counties  and  cities,  upon  the  application  of  the  keeper  of  the  jail,  when  requested  so  to 
do  in  writing  by  the  physician  doing  the  practice  at  the  jail  in  question,  all  felons  or 
prisoners  serving  terms  of  imprisonment  in  said  jail,  and  all  persons  who  may  be 
confined  in  said  jail  and  awaiting  trial,  who  have  contracted  any  such  contagious  or 
infectious  diseases  dangerous  to  the  public  health,  to  some  place  designated  by  the 
judge  of  the  county  or  corporation  court,  as  the  case  may  be,  wherein  it  exists,  and 


PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE        67 

when  said  prisoners  are  so  removed  they  shall  be  safely  kept,  and  receive  proper  care 
and  attention,  including  medical  treatment,  and  as  soon  as  they  are  restored  to  health 
they  shall  be  returned  to  the  jail  from  whence  they  were  moved,  unless  the  term  of 
those  who  have  been  convicted  of  any  offense  should  expire  during  the  time  of  their 
quarantine,  in  which  event  they  shall  be  discharged,  but  not  until  all  danger  of  their 
spreading  contagion  has  passed.  All  expenses  incurred  under  and  bv  reason  of  this 
act  shall,  as  to  prisoners  taken  from  the  penitentiary,  be  borne  by  the  state,  and  as  to 
persons  taken  from  the  jails  of  counties  and  corporations,  be  paid  by  the  respective 
cities  and  counties.     (1895-96,  p.  193.) 

General  considerations. —  There  is  a  tendency  to  raise  the  labor  union 
question  when  proposals  are  made  to  introduce  workshops  into  prisons. 
From  some  little  study  of  the  matter,  it  impresses  me  that  the  labor  unions 
have  not  been  as  antagonistic  to  the  matter  as  have  the  contractors  who 
desire  to  keep  up  the  abominable  prison  leasing  system.  While  prison  re- 
form is  important  we  should  not  swing  so  far  toward  reform  as  to  forget  the 
fact  that  the  malefactor  desers'es  proper  punishment.  No  matter  what  point 
of  view  one  takes  as  regards  the  punishment  of  crime,  there  is  no  excuse  for 
insanitary  conditions  or  cruelty  in  any  institution. 

Their  services  to  the  public  are  constantly  enlarging  and,  as  with  the  army 
and  navy,  the  work  in  peace  is  of  greater  moment  than  is  that  connected  with 
war  and  disorder.  These  branches  of  governmental  service  are  more  for 
the  prevention  of  war  and  crime  than  to  fight  battles  and  make  arrests.  With- 
out depreciating  their  services  in  the  latter  and  important  fields  of  action,  the 
armv,  the  navy,  and  the  police  are  doing  a  very  important  service  to  the 
country  in  preventing  various  woes  inclusive  of  disease.  Read  the  chapter 
upon  army  and  navy  hygiene,  and  it  will  be  seen  what  a  great  work  Is 
being  done  for  sanitation  by  these  national  policemen.  Local  police  can  be 
utilized  in  much  the  same  way.  While  police  duties  do  not  as  yet  embrace 
much  aside  from  the  maintenance  of  order,  the  larger  duties  are  gradually 
creeping  in  by  the  addition  of  special  police,  such  as  sanitary  and  ambulance 
police.  It  is  a  tedious  task  to  simply  patrol  a  beat  with  an  occasional  arrest 
for  excitement,  and  I  believe  many  officers  would  welcome  duties  of  a  more 
varied  character.  Also  it  stands  to  reason  that  if  higher  duties  are  exacted,  a 
higher  class  of  men  would  enter  the  work.  Recent  magazine  articles  impress 
one  with  the  idea  that  the  rank  and  file  of  city  police  would  be  men  of  correct 
deportment  and  without  "  graft,"  or  other  failings  attributed  to  them  if  they 
could  be  removed  from  under  the  dominion  of  crooked  politicians  and  busi- 
ness interests,  not  altogether  legitimate.  Of  such  matters  I  know  nothing, 
but  am  inclined  to  the  view  that  some  magazine  articles  are  a  bit  perfervid. 

Police  ambulances. —  One  reads  of  neglect  and  cruelty  in  connection 
with  the  police  ambulance  system.  Possibly  some  cases  reported  are  true, 
but  I  have  seen  so  much  good  done  and  so  many  lives  saved  by  the  service 
that  the  good  overwhelms  the  alleged  bad  features.  Photographs  are  shown 
of  our  Harrisburg  service,  which  uses  automobile  ambulances.  They  ride 
easy,  are  rapid,  and  make  a  very  quick  response  to  a  call.  It  is  a  difficult 
thing  to  diagnose  and  treat  a  case  upon  the  street  or  in  a  rapid  ambulance. 


68  HYGIENE 

and  it  is  to  be  expected  that  mistakes  will  be  made  where  differential  diagnosis 
is  difficult  or  involved.  The  so-called  "  ambulance  chaser  "  needs  to  be 
met  with  a  club  when  he  reaches  the  hospital.  There  is  no  occasion  for  phy- 
sicians upon  the  staff  of  a  hospital  to  give  them  any  information  or  privi- 
leges beyond  what  is  legally  necessary.  The  better  plan  is  for  the  hospital 
surgeon  to  take  no  interest  or  part  for  or  against  the  persons  making  claims 
or  wishing  to  settle  them,  as  such  matters  need  not  come  within  the  province 
of  the  medical  man  at  all.  Also  the  favoring  of  certain  hospitals  for  political 
reasons  is  beneath  contempt.  The  proper  fitting  of  a  police  ambulance 
depends  upon  local  conditions. 

The  police  matron. —  Women  understand  women's  nature  far  better 
than  do  men.  Many  unfortunate  girls  and  women  are  arrested  who  conceal 
facts  mitigating  or  extenuating  their  offenses.  A  police  matron  can  ferret 
this  out  and  can  often  do  better  by  the  case  by  getting  her  into  some  retreat 
or  institution  instead  of  into  prison.  The  peculiar  psychology  of  crime  need 
not  be  discussed  here,  but  the  simple  fact  remains  that  women  police  officers 
are  needed  just  as  are  female  detectives.  Proper  consideration  of  sex  makes 
the  matron  necessary.  Incidentally,  these  matrons  do  a  great  deal  of  good  in 
a  quiet  way  and  of  which  the  public  never  hears.  Certain  sanitary  matters 
properly  come  under  their  care. 

The  sanitary  police. —  These  men,  when  properly  trained  and  of  due 
ability,  are  not  only  useful,  but  may  become  highly  necessary  to  enforce  sani- 
tary regulations  and  quarantine.  They  should  be  taught  the  details  regard- 
ing disinfection,  since  so  much  public  disinfection  is  a  mere  farce  through  the 
ignorance  of  those  entrusted  with  the  work. 

Their  place  in  suppressing  vice. —  Gen.  Theodore  A.  Bingham,  former 
Police  Commissioner  of  New  York  city,  said,  in  an  article  in  Hampton's 
Magazine  (September,  1909) :  The  social  evil  "can  be  controlled ;  not  licensed, 
but  segregated  so  as  to  be  reduced  to  a  minimum.  Prostitution,  at  present 
scarcely  restricted  at  all  in  New  York,  but  rampant  on  the  lower  East  Side 
and  in  the  *  Tenderloin,'  demands  quarantining  just  as  do  yellow  fever  and 
smallpox.  Given  full  authority  to  grapple  with  this  scourge,  regarding  which 
decent  citizens  of  the  community  are  as  ignorant  as  children,  a  zealous  police 
commissioner  can  restrict  it  to  specific  districts  and,  with  the  aid  of  the  health 
department,  keep  it  under  absolute  control.  Not  only  would  this  reduce  by 
one  half  the  fearful  ravages  of  disease,  but  it  would  greatly  reduce  the  dangers 
to  which  the  youth  of  the  city  are  now  exposed  through  the  presence  of  well- 
appearing,  immoral  women  even  in  the  most  exclusive  apartment-house 
neighborhoods. 

"  Beyond  enforcing  segregation  the  police  are  powerless  to  act,  espe- 
cially when  this  vicious  and  appalling  evil  renders  such  rich  returns  to  poli- 
ticians for  their  own  profit  and  for  corrupting  the  police." 

Police  instruction  in  -first  aid  should  be  given  in  every  city,  and  also  to 
firemen  in  the  paid  service.  The  policeman  is  frequently  the  first  man  avail- 
able, especially  at  night.  I  have  found  the  officers  to  whom  I  have  lectured 
very  much  interested.     Germany  makes  a  general  public  factotum  of  the 


POLICE    AUTOMOBILE    AMBULANCE    SERVICE 


PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE       69 

policeman,  and  we  will  come  to  the  same  thing  in  this  country  eventually.     I 
have  great  faith  in  the  future  sanitary  value  of  the  police  department. 

Hospitals  for  the  Insane* 

Much  can  be  said  upon  a  subject  which  carries  with  it  such  vital  inter- 
ests, not  only  to  those  confined  in  these  institutions,  but  to  the  community 
at  large.  What  new  ideas  can  be  brought  forth  ?  It  is  easy  to  see  faults 
and  to  criticise,  but  is  it  equally  as  easy  to  supply  the  necessary  remedy  for 
those  evils  with  which  we  find  fault  ?  The  subject  of  this  chapter  leads  the 
reader  to  infer  that  the  author  has  mastered  this  difficult  question,  and  in 
the  short  space  allotted  to  him  would  point  out  clearly  to  them  the  duties  of 
those  good  men  at  the  head  of  these  important  institutions,  in  the  perform- 
ance of  their  work.  The  duties  of  these  institutions  as  regards  the  observ- 
ance of  laws  of  public  hygiene  and  health  are  already  well  known.  Knowing 
our  duty,  and  possessing  the  ability  to  perform  it  correctly,  does  not  always 
follow  each  other.  Of  course  it  is  the  duty  of  each  and  every  public  hospital 
to  see  that  its  inmates  are  properly  protected  from  influences  that  will  impair 
their  general  health,  and  at  the  same  time  it  is  their  duty  to  protect  the  public 
from  any  infection  which  may  arise  in  such  places.  But  is  the  great  difficulty 
of  such  an  action  on  the  part  of  the  officials  generally  reasonably  considered  ? 
I  am  speaking  of  the  hospitals  for  the  insane.  One  of  the  most  trying  of  all 
public  positions  is  that  of  superintendent  to  one  of  these  state  institutions.  A 
great  field  indeed  for  good  work,  but  one's  reward  must  be  looked  for  in  the 
great  hereafter,  because  I  have  never  known  it  to  appear  during  the  lifetime 
of  any  present  incumbent. 

In  case  a  patient  receives  a  black  eye,  loses  an  overcoat  or  a  pair  of  sleeve 
buttons,  makes  his  escape,  or  hangs  himself,  the  officer  in  charge  is  considered 
the  one  to  blame.  Or  should  the  condition  of  patients  be  such  that  visits 
from  friends  or  relatives  would  do  him  any  injury,  such  a  refusal  to  have  his 
friends  see  him  would  be  proof  positive  in  the  minds  of  those  receiving  this 
denial,  that  there  was  some  other  motive  for  the  refusal.  They  would  think 
that  the  patient  had  been  abused,  or  is  being  punished  in  some  way,  and  the 
officer  is  bringing  this  point  forward  as  a  good  excuse  to  shield  himself  for 
that  which  seems  sure  is  an  evil  act  on  his  part.  Now  if  these  officers  are 
meeting  with  obstacles  like  this  daily  in  the  administration  of  their  duties, 
what  would  be  the  result  if  the  public  were  refused  admission  entirely  to  this 
or  that  person  ?  He  is  in  quarantine,  there  is  an  infectious  disease;  that 
quarantine  in  the  minds  of  a  great  many  means  a  dark  cell.  If  the  super- 
stition and  prejudice  against  hospitals  for  the  insane  could  be  removed,  it 
would  be  one  of  the  greatest  benefits  to  that  unfortunate  class  of  people  who 
lose  their  minds  and  have  to  be  committed.  It  would  mean  hospital  treat- 
ment of  insanity  in  its  incipiency.  A  thing  we  do  not  see  now,  and  the  super- 
stition which  lurks  in  the  mind  of  every  one  who  has  relatives  in  hospitals,  viz. 
that  these  people  were  subject  to  neglect  and  abuse,  would  be  removed;  and 
it  would  add  as  much  comfort  to  those  at  home  as  it  would  give  benefit  to 
that  most  unfortunate  class  of  people  who  are  inmates  of  these  institutions. 
*ByW.  E.Wright,  M.D. 


70  HYGIENE 

Infection  does  not  always  originate  in  hospitals.  For  the  most  part 
patients  in  these  institutions  are  cleaner,  better  housed,  and  better  fed  than 
they  ever  were  before  their  admission.  But  on  visiting  days  great  crowds 
of  the  curious  swarm  through  the  wards,  in  the  most  part  a  class  of  people  who 
have  no  interest  in  the  study  of  insanity  or  the  conditions  of  the  insane,  but 
who  are  idle  and  curious.  They  stare  with  astonishment  at  the  homelike 
appearance  of  the  wards,  and  the  sane  manner  and  appearance  of  the  inmates, 
they  giggle,  shy  off,  and  appear  to  assume  fear  of  attack,  but  at  the  same  time 
are  disappointed,  and  their  appetites  for  the  sight  of  suffering  and  general 
disorder  they  had  hoped  to  see  is  not  satisfied.  Why  should  not  these  curious 
people,  who  come  in  many  instances  from  the  slums  of  our  towns  and  cities, 
bring  in  contagion  ? 

In  the  times  of  great  commercial  prosperity  it  is  almost  impossible  to 
keep  efficient  employees  in  these  institutions,  and  it  is  equally  impossible  to 
employ  new  ones  who  are  efficient.  During  this  period  the  officers  are  forced 
to  employ  a  class  that  are  in  many  respects  themselves  degeneiate.  They 
could  not  succeed  in  getting  such  employment,  if  the  institutions  were  not  in 
destitute  circumstances  as  regards  employees.  These  people  come  from 
unknown  districts,  are  themselves  dirty  and  unkept,  and  are  put  in  wards  to 
have  charge  of  clean  patients.  They  are  liable  to  bring  all  kinds  of  infection 
with  them.  It  is  from  this  particular  source  that  vermin  is  introduced  into 
public  hospitals,  and  when  this  pest  once  gets  a  lodging,  every  one  who  has 
had  hospital  experience  knows  how  difficult  a  matter  it  is  to  get  clean  of  it. 
And  is  not  this  an  infection  ? 

With  the  exception  of  tuberculosis,  it  has  been  my  experience  that  the 
various  infectious  diseases,  when  developed  in  hospitals  for  the  insane,  are 
more  frequently  carried  there  from  without  than  it  has  been  that  the  infection 
arises  within  the  institution  itself.  A  case  of  diphtheria  in  a  patient  may  be 
traced  to  the  employment  of  a  new  nurse  who  comes  from  a  home  recently 
infected.  A  case  of  scarlet  fever  develops  when  an  attendant  goes  to  a 
friend's  house  in  the  city,  though  he  knows  it  is  placarded.  A  case  of  typhoid 
fever  develops  from  food  brought  by  relatives  from  a  home  where  there  is  a 
case  of  the  disease.  There  are  really  so  many  minor  ways  by  which  infection 
can  reach  the  inside  of  a  public  hospital,  that  I  think  much  weight  should  be 
given  to  its  importance,  and  especially  should  promiscuous  visiting  to  these 
wards  be  carefully  guarded  against. 

The  state  of  Pennsylvania  has  many  large  institutions  built  with  a  specific 
purpose  of  giving  care  and  maintenance  to  the  insane.  These  institutions  are 
given  the  name  "  hospital."  In  addition  to  these  there  is  provided  an  insti- 
tution for  those  unfortunates  who  are  no  longer  considered  curable,  and  thus 
are  not  amenable  to  hospital  care.  These  people,  if  they  are  able-bodied, 
and  capable  of  self-support  at  ordinary  labor,  are  committed  to  this  specific 
institution,  which  is  given  the  name  "  asylum."  It  is  necessary  that  a  person 
shall  have  been  insane  one  year,  and  that  he  or  she  be  able-bodied  and  capa- 
ble of  working,  in  order  to  be  eligible  to  a  residence  in  this  asylum.  When  I 
interpret  the  definition  of  hospital  and  that  of  as}'lum,  the  meaning  of  the 


PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE       71 

terms  is  a  widely  different  one.  A  hospital  would  naturally  be  a  place  where 
the  acutely  sick  are  cared  for;  an  asylum  is  a  place  for  safe  keeping  and  pro- 
tection. Now  when  we  consider  the  fact  that  in  those  institutions  the  state 
calls  "  hospital  "  not  more  than  five  per  cent  (and  this  probably  is  too  high) 
of  their  number  are  considered  curable,  and  the  vast  number  of  patients  there 
are  merely  crowded  together  in  wards  which  have  barred  windows  and  locked 
doors,  in  their  overcrowded  conditions,  two  patients  occupying  a  space  origi- 
nally built  for  one,  the  corridors  or  day  halls  are  crowded  with  poor,  demented 
people  who  much  prefer  lying  on  the  floor  in  some  dark  corner  of  the  room  to 
occupying  comfortable  seats  at  an  open  window,  and  who  are  necessarily 
breathing  a  polluted  atmosphere  constantly,  the  only  change  in  the  monotony 
of  the  life  of  these  individuals  is  a  visit  to  the  dining  room,  and  then  to  a  large 
dormitory  to  sleep  at  night;  perhaps  once  or  twice  a  day  in  good  weather  the 
most  trustworthy  of  these  patients  will  be  taken  out  for  a  walk  about  the 
grounds  for  an  hour  or  more.  When  we  consider  the  environment,  and  the 
mental  condition  of  this  class  of  people,  which  would  be  the  better  term  for 
such  an  institution  —  hospital  or  asylum  ?  It  seems  to  me  that  asylum  fits 
in  with  the  description  admirably,  and  yet  Pennsylvania  had  five  such  chronic 
institutions  when  the  place  near  Wernersville  was  built,  and  to  designate  it 
from  the  others  known  as  hospitals,  was  called  Asylum  for  the  Chronic  Insane. 
This  has  always  appeared  very  unfortunate  to  me,  when  the  fact  was  con- 
sidered that  this  great  commonwealth  was  already  the  possessor  of  five 
institutions  which  were  then  caring  for  the  chronic  insane,  had  this  idea  only 
been  reversed,  and  instead  of  another  chronic  insane  colony,  a  hospital  in  its 
truest  sense  been  constructed  where  acute  cases  could  have  been  received  and 
properly  studied  and  treated.  Then,  after  a  stated  period,  say  a  year,  there 
should  be  found  no  benefit,  and  the  case  declared  an  unfavorable  one,  let 
such  a  case  then  be  transferred  to  one  of  the  chronic  asylums  already  in 
existence. 

With  a  colony  of  fifteen  hundred  or  more  people  crowded  together  under 
unsanitary  conditions,  it  is  but  natural  to  expect  infection  to  crop  out  at  vari- 
ous intervals.  As  I  have  already  pointed  out,  the  inmates  of  these  institu- 
tions are  living  in  an  atmosphere  depressing,  both  mentally  and  physically, 
their  vitality  is  lowered  by  disease,  and  their  resistive  forces  are  also  greatly 
diminished,  making  them  shining  marks  when  exposure  is  brought  about.  In 
institutions  of  this  kind  the  only  way  to  prevent  a  spreading  of  the  infection 
is  a  prompt  and  proper  isolation  of  the  case.  When  there  has  been  no 
thought,  and  no  provision  made  for  such  an  emergency,  it  taxes  the  ingenuity 
of  those  in  charge  to  meet  it,  when  they  make  a  discovery  of  a  case  of  scarlet 
fever  or  diphtheria  in  a  ward  with  seventy  or  one  hundred  patients.  The  first 
diflficulty  is  the  fact  that  in  these  overcrowded  places  every  bed  is  occupied, 
the  patient  probably  has  been  a  mild  case,  and  was  sleeping  in  a  dormitory 
with  twenty-five  or  more  patients.  It  is  now  necessary  to  get  him  in  a  single 
room.  There  is  no  single  room  available.  The  room  for  isolation  must  be 
large  enough  to  accommodate  an  attendant  also,  because  the  patient  cannot 
be  left  alone.     The  room  must  be  in  a  secluded  part  of  the  ward,  because 


72  HYGIENE 

other  patients  must  be  protected;  there  must  be  water  closet  and  bath  facili- 
ties; also  an  arrangement  must  be  made  for  his  meals  to  be  served,  and  the 
proper  disinfection  of  dishes  and  bed  clothing,  etc.  After  making  a  half  dozen 
or  more  changes,  and  inconveniencing  that  number  or  more  persons,  and 
making  them  more  or  less  uncomfortable,  such  a  case  of  infection  is  generally 
taken  care  of  in  a  room  on  the  ward,  or  in  a  part  of  the  building  which  to  the 
mind  of  the  officer  serves  as  the  best  facilities  at  hand  for  such  an  isolation. 
In  the  majority  of  cases  it  is  not  ideal.  The  next  day  in  another  ward,  per- 
haps, you  will  find  a  case  of  diphtheria.  This  time  the  subject  of  the  disease  is 
a  violent  and  treacherous  patient.  Maybe  he  cannot  be  trusted  in  a  room 
with  other  patients,  and  the  room  which  he  occupies  must  have  guards  on  the 
windows  and  inside  shutters  to  protect  him  from  his  own  violence,— what 
is  to  be  done  with  this  case  ?  He  cannot  be  left  in  the  ward,  because  he 
occupies  a  room  —  say  about  the  center  —  where  every  other  occupant  comes 
in  close  contact  many  times  each  day.  It  is  the  same  old  hardship,  some  one 
else  has  to  give  up  his  room, —  but  where  is  the  last  patient  to  sleep  ?  You 
will  say  at  once,  "  In  the  room  of  the  patient  who  has  just  been  moved  "  ; 
but  this  cannot  be  done,  because  this  room  has  to  be  fumigated.  "  Well, 
why  not  fumigate  it  ?  "  Because  it  may  be  late  in  the  evening  when  such  a 
case  is  discovered,  and  there  is  no  time  for  the  proper  fumigation  and  ventila- 
tion in  order  to  have  it  ready  for  the  patient  to  sleep  in  that  night.  All  such 
questions  are  constantly  arising,  and  have  to  be  promptly  met  in  institutions 
for  the  insane.  It  is  one  of  the  most  trying  problems  a  physician  has  to  deal 
with,  and  could  be  simplified  so  readily  by  establishing  a  ward  or  building 
for  the  isolation  of  such  infectious  cases.  In  every  institution  for  the  insane 
there  should  be  an  isolation  ward,  or  hospital  for  contagious  and  infectious 
cases,  arranged  with  diet  kitchen,  sterilizing  room,  bath,  and  comfortable 
quarters  for  those  who  have  to  nurse  such  cases.  Special  sterilizers  in 
laundry  for  the  care  of  bedding  and  clothing,  etc.,  should  also  be  provided. 

In  these  institutions  the  appearances  of  infectious  diseases  are  more  to  be 
feared  than  the  outbursts  of  violence  among  the  inmates.  A  typhoid  case,  if 
not  properly  protected,  may  be  the  nucleus  for  an  epidemic.  Typhoid  fever  is, 
as  we  all  know,  a  water-borne  disease,  but  there  are  other  means  of  carrying 
the  infection.  The  germ  is  generally  introduced  through  the  ailmentary 
tract.  I  have  known  more  than  one  case  in  a  public  institution  to  have 
originated  by  taking  food  brought  them  by  their  relatives  when  there  had 
been  a  recent  case  of  typhoid  in  the  home  of  that  individual.  These  visitors 
are  admitted  to  the  various  public  institutions  to  see  their  relatives  on  special 
days  in  each  week.  They  always  feel  it  is  their  duty  to  take  the  sick  some- 
thing to  eat,  and  the  patients  generally  expect  them  to  do  so.  It  is  out  of  the 
question  for  the  superintendent  in  charge  of  such  an  institution  to  make  an 
inspection  of  each  of  these  individual  parties,  and  ask  regarding  contagious 
diseases  in  their  homes.  Even  if  such  a  plan  were  feasible,  the  parties  would 
not  always  give  correct  statements  regarding  them.  Their  lack  of  knowledge 
and  appreciation  of  the  importance  of  the  subject  makes  them  careless,  and 
they  would  enter  a  denial,  if  they  thought  by  doing  so  they  would  be  able  to 


PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE       73 

gain  permission  to  see  the  patient.  I  mention  this  as  a  source  of  infection 
that  is  hard  to  guard  against,  but  it  is  an  important  one,  and  must  be  given 
careful  study  as  to  what  measures  could  best  be  applied  to  prevent  it.  But 
apart  from  the  outside  danger  of  carrying  infection  to  the  inmates  of  these 
institutions,  there  are  the  conditions  in  these  places  in  particular  which  I  have 
already  mentioned,  and  which  seem  to  me  to  be  a  hotbed  for  the  development 
of  such  infection  as  tuberculosis. 

How  does  the  health  officer  recommend  that  these  tuberculosis-favoring 
conditions  should  be  met  in  an  insane  hospital  ?  In  the  first  place  let  me 
picture  the  conditions  as  I  have  seen  them,  and  tried  to  meet  them  for  a 
period  of  a  dozen  years  or  more.  Old  buildings,  poorly  ventilated,  badly 
heated,  very  little  sunshine,  capacity  overcrowded  forty  per  cent,  inmates 
majority  are  chronic,  demented,'  restless,  untidy,  irritable,  and  very  careless 
in  their  habits.  A  great  many  prefer  to  lie  on  the  floor  in  some  corner  of  the 
room,  their  faces  turned  to  the  wall,  and  become  irritable  when  they  are 
asked  to  sit  in  a  comfortable  chair  near  an  open  window.  Some  of  these 
people,  if  not  watched  constantly,  will  remain  in  the  chair  but  a  few  minutes 
before  they  return  to  their  old  positions  on  the  floor  in  the  corner  of  the  room. 
These  people  are  breathing  bad  air  constantly,  seldom  getting  in  the  sun,  all 
the  exercise  they  get  is  going  to  and  from  the  ward  to  the  dining  room,  and  the 
dormitory  to  sleep.  Is  anything  more  potent  for  the  predisposition  to  the 
development  of  tuberculosis  than  the  life  of  an  individual  with  such  en- 
vironments r  These  people  do  develop  the  disease  with  alarming  frequency. 
They  are  weak  to  begin  with,  their  mental  condition  is  that  of  a  chronic  dis- 
ease, their  resistive  force  is  lowered,  their  circulation  is  poor,  and  their  diges- 
tion is  bad.  I  believe  if  the  tuberculin  test  Vv^ere  made  upon  all  the  patients 
in  the  disturbed  and  overcrowded  wards  of  our  state  ond  county  institutions 
which  care  for  the  insane,  that  there  would  be  a  positive  reaction  in  at  least 
twenty  per  cent  of  the  cases.  These  cases  in  their  various  stages  are  mingling 
with  the  other  inmates  daily.  In  the  advanced  cases,  or  those  that  have  been 
recognized,  there  is  some  attempt  at  isolation  for  those  of  mild  mental  dis- 
turbance. If  they  are  not  violent,  or  if  they  are  too  feeble  to  do  physical 
damage  to  others,  they  are  placed  in  an  infirmary  ward,  or  such  room  with 
more  sunlight  and  better  ventilation  than  they  had  when  they  developed  the 
disease.  These  patients  have  always  been  careless  in  their  habits,  they  ex- 
pectorate promiscuously,  and  they  cannot  be  taught,  or  will  not,  the  habits  of 
hygiene,  which  I  mentioned  in  the  beginning  of  this  subject.  In  my  mind 
they  are  far  more  dangerous  individuals  even  in  this  bedridden  and  exhausted 
state  than  they  were  when  in  the  strength  of  their  mania  and  muscular  bodies 
they  were  inclined  to  assault  others.  These  patients  expectorate  over  their 
bedding  and  the  floor  about  their  beds.  Often  in  an  irritable  mood  their 
weapon  of  defense  is  to  expectorate  in  the  face  of  an  attendant  who  wishes 
to  change  their  clothing  or  administer  some  aid.  These  are  dangerous 
problems  which  the  medical  officers  of  these  institutions  have  to  deal  with 
constantly.  The  peculiar  nature  of  these  individuals  under  their  care  makes 
it  a  major  problem  in  comparison  with  the  conditions  which  are  met  by  the 
general  practitioner  and  the  various  dispensary  physicians  throughout  the 


74  HYGIENE 

state.  They  are  dealing  with  chronic  mental  conditions,  in  the  majority  of 
cases  incurable,  together  with  a  dreaded  physical  malady,  the  hygiene  and 
prophylaxis  of  which  depends  in  great  part  upon  the  individual  himself. 
These  subjects  now  under  discussion  pay  no  attention  whatever  to  such 
methods,  and  cannot  be  taught  to  do  so.  I  know  there  has  been  written  a 
great  deal  recently  concerning  the  tent  life  of  the  tubercular  insane.  Pho- 
tographs illustrating  the  work  of  attending  physicians  in  various  state  institu- 
tions in  New  York  have  been  displayed,  for  which  the  authors  should  receive 
due  credit.  Only  the  very  mild  cases  could  receive  the  benefit  of  this  outdoor 
arrangement,  and  the  violent  case,  with  his  resistive  tendencies,  was  still 
locked  up  in  the  ward  with  the  other  inmates,  who  were  forced  to  come,  if  not 
in  direct  contact  with  him,  were  compelled  to  breathe  the  same  atmosphere, 
which  may  have  possibly  been  made  dangerous  by  his  filthy  habits  and  care- 
less expectoration. 

In  the  past  few  years  Pennsylvania  must  be  given  credit  for  efforts  in  the 
better  housing  of  the  insane.  The  old  buildings,  badly  ventilated  and  poorly 
heated,  which  were  referred  to  a  moment  ago,  have  been,  by  the  persistent 
efforts  of  a  worthy  superintendent  and  a  determined  board  of  trustees,  torn 
down.  Only  two  are  now  left.  In  the  place  of  these  old  buildings  have  been 
constructed  modern  fireproof  buildings  on  the  cottage  plan,  which  not  only 
insure  a  better  classification  of  the  inmates,  but  give  them  more  comfortable 
apartments  with  cheerful  surroundings,  good  light,  plenty  of  sunshine,  suc- 
cessful ventilation,  and  good  heating.  The  plan,  when  completed,  will  be  a 
pride  to  the  state  and  a  monument  to  the  memory  of  those  good  officers  who 
for  years  have  fought  the  hardest  obstacles  and  reverses  in  order  to  carry  out 
their  plans.  The  overcrowding  in  some  of  the  departments  here,  however, 
continues,  and  the  tubercular  insane  are  still  there.  It  may  be  with  these 
improved  environments  the  percentage  of  tubercular  cases  in  future  years  will 
be  lowered,  but  the  means  of  isolating  such  cases,  and  those  of  other  infections, 
has  not  been  provided.  The  same  condition  of  affairs  exists  in  every  hospital 
in  our  state.  I  have  reference  to  a  hospital  building  for  isolating  the  infectious 
diseases. 

To  sum  up,  then,  the  duty  of  every  institution  housing  the  insane  when 
infectious  diseases  make  their  appearance  is,  first,  to  establish  isolation  and 
disinfection.  Quarantine  regulations  as  provided  by  the  state  board  of 
health  should  be  closely  observed.  The  hospital  should  be  properly  screened 
against  the  infection  from  insects,  such  as  flies,  mosquitoes,  roaches,  rats,  etc. 
To  carry  out  these  plans  properly,  every  such  institution  should  be  provided 
with  the  proper  isolation  ward  or  building,  which  is  distinct  from  the  rest 
of  the  buildings,  and  should  be  used  for  no  other  purpose.  With  such  a  pro- 
vision in  every  institution  there  would  be  fewer  instances  in  which  the  second, 
the  third,  or  in  a  particular  instance  one  hundred  and  fifty  cases  follow  the 
first  infection. 

Notes  by  the  Editor. —  The  preceding  very  excellent  paper  by  my  colleague  in 
the  neurologic  work  in  Harrisburg  Hospital  tends  to  confirm  my  views  that  the  average 
insane  person  does  not  receive  the  kind  of  treatment  best  adapted  to  cure.     His  point 


PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE       75 

is  well  taken  that  the  average  institution  is  an  asylum  and  is  not  a  hospital.  In  the  first 
section  of  this  chapter  upon  penal  institutions  it  will  be  observed  that  the  old  ideas 
of  prisons  were  a  place  to  shut  up  people  away  from  society,  but  that  the  new  idea  is 
to  so  train  the  prisoner  as  to  return  him  again  to  society  and  industrial  usefulness. 

It  will  not  be  long,  in  my  view  of  the  case,  when  the  same  progressive  ideals  will 
abolish  the  present  type  of  asylums  for  the  insane,  and  that  establishments  similar 
to  the  Craig  Epileptic  Colony  of  Sonyea  will  be  opened  for  the  treatment  of  insane 
people  presenting  some  reasonable  promise  of  cure  or  improvement. 

A  movement  in  this  direction  has  been  initiated  by  the  establishment  of  psy- 
chopathic hospitals.  It  was  my  pleasure  to  inspect  the  one  at  Ann  Arbor,  Michigan, 
and  a  photograph  of  the  building  accompanies  these  remarks.  The  following  printed 
matter  is  taken  from  the  first  biennial  report  of  the  hospital,  and  from  an  editorial  in 
the  August,  1909,  Pennsylvania  Medical  Journal. 

The  state  of  Michigan  has  the  creditable  position  in  the  history  of  psychiatry  in 
America  of  being  the  first  to  establish  a  university  hospital  for  the  care  and  treatment  of 
mental  diseases,  and  of  providing  adequate  facilities  for  the  instruction  of  medical 
students  of  the  university  regarding  insanity.  The  achievement  of  this  hospital  is 
almost  entirely  due  to  the  late  Dr.  William  J.  Herdman.  .  .  .  As  a  result  of  his  in- 
terest and  initiative  there  was  passed  by  the  Michigan  State  Legislature  in  1901  (Act 
161,  Public  Acts  of  1901)  an  act  to  provide  for  the  construction  and  equipping  of  a 
psychopathic  ward  upon  the  hospital  grounds  of  the  University  of  Michigan,  and  to 
appropriate  the  sum  of  ^50,000  therefor. 

It  must  be  borne  in  mind  that  there  were  no  precedents  to  follow  in  drafting  a 
comprehensive  set  of  provisions  for  the  organization  and  administration  of  a  new 
hospital.  The  problem  was  to  establish  an  institution  of  the  type  desired  in  the  usual 
state  organization  for  the  care  of  the  insane.  It  was  essential  that  there  should  be 
harmonious  co-operation  with  the  asylums  of  the  state,  and  at  the  same  time  the  new 
hospital  should  be  an  integral  part  of  the  University  Medical  School.  .  .  .  Patients 
may  be  admitted  to  the  psychopathic  hospital  by  any  of  the  following  procedures: 

I.  Any  judge  of  probate  may  commit  any  insane  person  to  the  psychopathic 
hospital  whom  the  director  regards  as  a  suitable  patient  for  the  hospital. 

II.  A  person  may  be  sent  to  the  psychopathic  hospital  as  an  observation  patient 
for  a  period  not  longer  than  thirty-five  days  for  any  of  the  following  reasons: 

1.  When  the  judge  of  probate  may  have  doubt  as  to  whether  the  person  is  insane 
and  desires  such  data  as  could  be  furnished  by  an  observation  under  such  conditions 
as  the  psychopathic  hospital  can  furnish. 

2.  When  the  mental  condition  of  the  person  is  associated  with  complicating 
physical  disease  which  may  be  benefited  by  treatment  by  the  physicians  and  surgeons 
of  the  general  hospitals  of  the  university. 

3.  When  the  judge  of  probate  regards  a  decree  of  insanity  as  inadvisable  as 
when  the  disease  will  be  of  such  short  duration  as  to  recover  within  the  period  of  thirty- 
five  days.    .    .    . 

The  patients  who  come  to  the  hospital  are  afflicted  with  different  forms  of  mental 
diseases.  Some  are  noisy  and  restless,  some  are  depressed  and  apprehensive,  and 
some  bedridden  from  serious  disease  of  the  nervous  system.  Others  come  for  relief 
from  abnormal  mental  states  which  are  not  classed  as  insanities.  These  conditions 
are  commonly  known  as  psychopathic  states,  and  it  is  these  that  this  hospital  can  do 
most  for.  Such  persons  have  various  hysterical  manifestations,  severe  forms  of  nervous 
prostration,  or  are  troubled  with  fears  of  one  kind  or  another  that  make  their  lives 
miserable.  It  is  obvious  that  such  a  variety  of  conditions  as  these  just  mentioned 
need  different  arrangements  for  treatment. 


76  HYGIENE 

The  considerable  number  of  patients  seeking  treatment  for  various  psychopathic 
conditions,  and  who  are  not  insane,  must  be  cared  for  apart  from  those  who  are  insane. 
It  is  not  an  uncommon  occurrence  for  patients  of  this  class  who  come  to  the  hospital, 
to  refuse  to  remain  when  they  learn  that  they  cannot  be  given  accommodations  apart 
from  those  who  are  insane.  The  few  of  these  patients  who  are  brave  enough  to  come 
into  the  hospital  under  ihe  conditions  which  now  exist  are  greatly  benefited  by  the 
treatment.  However,  i^  is  always  apparen.  chat  they  would  do  better  if  they  could  be 
kept  from  contact  with  those  who  are  insane.  If  this  were  possible,  many  others  who 
could  be  benefited  would  enter  the  hospital.    .    .    . 

In  addition  to  its  duties  to  its  patients  the  psychopathic  hospital  is  a  part  of  the 
state's  educational  system,  and  will  have  a  part  in  the  training  of  the  future  physicians 
who  will  have  the  care  and  early  treatment  of  those  mentally  disturbed  throughout 
the  state.  Since  the  opening  of  the  hospital,  students  of  the  medical  department  of 
the  state  university  have  enjoyed  opportunities  for  the  studying  of  mental  diseases 
not  possible  elsewhere.  Clinical  lectures  on  insanity  have  been  given  each  week  to 
senior  medical  students.  The  results  of  such  practical  instruction  must  be  apparent 
to  all.    ... 

STATE  PSYCHOPATHIC  HOSPITAL  AT  UNIVERSITY  OF  MICHIGAN 

The  first  biennial  report  of  this  institution,  of  which  Dr.  Albert  M.  Barrett  is 
medical  director,  has  just  been  issued  and  contains  much  of  general  interest.  The 
passages  found  on  a  preceding  page  are  abstracted  from  the  report. 

Two  hundred  and  thirty-nine  patients  were  admitted  into  the  hospital  from  its 
opening  until  June  30,  1908.  These  cases  have  been  analyzed  in  the  most  interesting 
and  instructive  way  by  Dr.  Barrett.  The  Kreplin  classification  is  largely  adopted. 
The  relative  frequency  of  the  various  psychoses  will  be  seen  by  the  following  per- 
centages which  Dr.  Barrett  gives:  Mania  depressive,  17.1;  dementia  praecox,  16.7; 
alcoholic  insanity,  5;  general  paralysis,  7.9;  hysteria,  8.4.  Smaller  groups  include 
melancholia,  paranoia,  senile  dementia,  imbecility,  cerebral  syphilis,  Huntingdon's 
chorea,  etc. 

The  psychopathic  hospital  at  Albany,  N.  Y.,  and  the  psychopathic  ward  in  con- 
nection with  the  St.  Francis  Hospital  in  Pittsburg  have  for  some  years  been  doing 
excellent  work;  now  this  larger  and  broader  experiment  of  a  state  psychopathic 
hospital  in  intimate  connection  with  a  university  will  be  watched  with  greatest  in- 
terest. This  hospital  aims  to  bring  not  only  "  insanity,"  but  conditions  allied  more  or 
less  closely  to  it  under  the  same  careful  supervision,  observation,  and  treatment  as 
are  now  afforded  persons  sick  from  what  are  called  physical  diseases.  Johns  Hopkins 
University  is  preparing  to  build  a  psychopathic  clinic  which  is  made  possible  by  a  large 
fund  given  by  Mr.  Phipps.  Dr.  Adolph  Meyer,  who  has  been  selected  for  the  head  of 
the  proposed  clinic  in  Baltimore,  is  at  work  studying  out  plans  for  it.  Doubtless  when 
this  building  is  completed  there  will  be  incorporated  in  it  all  or  most  of  what  is  best 
and  most  advanced  in  psychiatry.  Altogether  it  would  seem  that  the  way  has  now  been 
opened  for  psychopathic  hospitals  in  connection  with  universities  and  with  other  hos- 
pitals in  large  cities  where  medical  men,  trained  in  this  particular  branch  of  internal 
medicine,  can  be  secured. — D. 

This  movement  is  bound  to  grow,  and  will  result  in  the  early  treatment  of  mental 
diseases,  a  consummation  that  will  save  to  the  state  and  to  society  much  more  than 
will  the  new  hospitals  cost.  The  colony  and  industrial  treatment  of  less  encouraging 
cases  will  also  reduce  the  cost  of  looking  after  these  people. 

I  have  been  reading  with  interest  two  old  books,  "  Mental  Hygiene,"  by  I.  Ray, 


^'1      . 


MICHIGAN  STATE  PSYCHOPATHIC  HOSPITAL  AT  ANN  ARBOR 
PORTION   OF  THE  "tOMBS"   PRISON,   NEW  YORK  CITY 


PENAL  INSTITUTIONS  AND  HOSPITALS  FOR  THE  INSANE       77 

M.D.  (1863),  and  "  The  Use  of  the  Body  in  Relation  to  the  Mind,"  by  Geo.  Moore, 
M.D.  (1847).  The  first  book  is  purely  scientific,  while  the  second  one  includes  the 
spiritual  and  religious  phases.  And  now  if  the  reader  turns  to  the  chapter  upon 
epidemics  and  reads  there  about  the  dancing  mania  of  the  middle  ages,  and  realizes 
that  various  cults  and  alleged  religions  of  to-day  are  really  succeeding  in  engrafting 
a  sort  of  mania  upon  their  deluded  followers  that  may  eventuate  as  disastrously  as 
did  the  middle  ages  cults,  he  will  come  to  realize  that  these  old  books  by  physicians 
should  have  been  taken  more  seriously,  and  that  we  owe  it  to  our  own  age  to  study 
and  teach  a  sane  view  of  the  influence  of  mental  impressions  upon  bodily  functions  and 
diseases.  In  other  words,  we  need  to  study  not  merely  how  to  treat  incipient  insanity, 
but  we  must  learn  how  to  prevent  such  disasters  as  well.  But  the  subject  is  too  big 
to  pursue  here.  Just  permit  me  to  say  that  the  clergy  Vv'ill  not  add  much  of  value  to 
our  knowledge  unless  they  abandon  present  methods,  and  both  clergymen  and  medical 
men  can  learn  much  by  a  study  of  some  of  the  old  literature  written  before  every 
writer  felt  that  his  chief  task  consisted  in  assailing  or  explaining  Eddyism.  History 
does  that.  What  we  need  to  do  is  to  begin  over  again  and  view  the  question  in  the 
wide  attitude  of  sociology  and  what  we  may  call  mental  sanitation. 

The  following  editorial  appeared  in  the  Medical  Council  for  November, 
1909: 

DREAMLAND  AND  INSANITY 

The  most  pleasant  of  dreams  are  those  that  relate  to  ourselves,  and  the  most 
dangerous  that  we  are  greater  than  our  fellows.  Joseph,  of  biblical  lore,  tried  the 
latter  and  won  out,  and  he  has  had  many  imitators  who  lost  their  all.  The  worst 
mundane  loss  is  our  reason,  but  few  realize  how  serious  a  matter  it  is  to  even  have  it 
impaired. 

We  have  just  had  related  to  us  a  distressing  case  of  insanity  in  which  the  un- 
fortunate man  imagined  he  possessed  occult  power,  and  that  his  enemies  were  hypno- 
tists. In  going  through  his  eff'ects  it  was  found  that  he  was  a  "  graduate  "  of  a  corre- 
spondence school  of  magnetic  healing,  and  was  accredited  with  wonderful  healing 
virtue.  Another  "  diploma  "  declared  he  was  a  made-by-mail  hypnotist  and  capable 
of  manifold  stunts  of  entertaining  and  healing.  Numerous  kinds  of  new  thoughts 
and  cooked-over  occultism,  commercialized  esoteric  specialties,  spiritualism  up  to 
date,  oriental  mysticism  and  all  that  line  of  flubdub  were  represented  in  a  miserable 
lot  of  well-thumbed  magazines  and  booklets,  most  of  which  endeavored  to  assail 
medicine  and  medical  men. 

We  had  no  idea  that  so  many  swindlers  were  fishing  for  suckers  with  such  ancient 
bait,  but  when  we  realize  that  vanity  is  inversely  strengthened  as  intelligence  is  weak- 
ened, we  can  see  millions  in  it  for  the  mail-order  character  builders  who  promise 
"  to  develop  latent  forces  and  a  strong  personal  magnetism  guaranteed  to  make  any 
man  or  woman  successful  in  anything  undertaken." 

Unfortunately,  learning  to  read  does  not  breed  sense,  and  there  are  millions  of 
readers  whose  superstitions  are  only  increased  by  reading  the  superstitions  of  others. 
Superstition  breeds  supernaturalism  and  it,  in  turn,  superegotism,  and  the  ignorant 
class  who  are  fleeced  by  these  esoteric  fakers  are  the  most  superlative  egotists  in  the 
world.  Implant  this  upon  an  already  weakened  mind  and  disaster  follows.  When 
the  world  sobers  up  from  its  present  worshiping  at  the  shrine  of  the  cults  that  range 
from  the  ignorant  mail-order  hypnotist  to  clerical  mentalopathy,  but  are  at  bottom  the 
same  thing  assorted  for  different  minds,  there  will  be  a  trail  of  wrecked  minds  and 
crowded  asylums. 


78  HYGIENE 

"  The  saving  grace  of  common  sense  "  is  as  necessary  for  the  mind  as  is  the  grace 
of  religion  for  the  soul.  We  physicians  have  been  saving  bodies;  let  us  realize  that 
we  can  save  minds  as  v^ell.  Prevention  is  the  cry  in  nearly  all  diseases.  Let  us  start 
a  propaganda  to  aid  in  the  prevention  of  mental  diseases.  Better  far  prevent  them 
than  to  hold  religious  clinics  and  experiment  with  all  the  ancient  quackery  ever  devised 
or^the  making  of  fools  out  of  idiots. 


Chapter  V 
MATERNITIES* 


Introductory — Early  maternities — Social  considerations — Modern  institutions 
— Objections  urged — Illegal  maternities — Laws  regulating  all  institutions  and  with 
especial  reference  to  the  statutes  of  Ohio — Ethical,  professional,  and  religious 
considerations. 

AMONG  the  instincts  or  primary  impulses  of  mankind  a  very  important 
one  is  that  which  leads  to  the  propagation  of  the  race.  It  presents 
more  of  the  complicated  problems  of  developing  civilization  than  perha  ps 
do  all  others  combined.  Among  these  important  problems  are  to  be  found 
the  question  of  the  care  of  the  mother  during  her  period  of  gestation  and 
labor,  and  the  care  of  the  children  until  they  reach  an  age  at  which  is  it  thought 
proper  to  let  them  undertake  their  own  maintenance,  largely  depending  upon 
the  stage  of  progress  in  the  arts  and  sciences  which  has  been  reached  by  the 
community  in  which  they  are  born  and  reared. 

The  ideal  condition  of  mankind  would  be  one  in  which  all  families,  each 
consisting  of  one  father  and  one  mother,  enjoy  a  sufficient  income  to  enable 
them  to  maintain  a  comfortable  home.  One  has  but  to  take  a  cursory  view 
of  the  different  nations  of  the  world,  or  even  to  look  around  him  in  his  own 
community,  to  realize  how  frequently  these  conditions  are  imperfectly  enjoyed 
or  wanting  altogether.  Many  homes  are  not  properly  equipped  for  the  care 
of  the  parturient  woman,  and  many  women  who  find  themselves  in  the  con- 
dition of  impending  motherhood  have  no  home  at  all. 

In  no  respect  is  the  progress  of  civilization  more  marked  than  in  the 
development  of  institutions  for  the  proper  care  of  those  who  are  not  able  to 
care  for  themselves.  Among  the  last  to  be  considered  in  the  development 
of  such  public  institutions  have  been  those  providing  for  the  wants  and 
necessities  of  indigent  mothers,  either  married  or  single. 

The  earlier  maternities  were  established  solely  for  the  purpose  of  pro- 
viding a  place  where  poor  but  respectable  married  women  could  be  properly 
taken  care  of  during  their  accouchement.  The  reasons  for  restricting  the 
services  of  such  an  institution  to  respectable  married  women  have  been  so 
strongly  expressed  by  the  founders  of  The  British  Lying-in  Hospital  for 
Married  Women,  established  in  London,  in  1747,  that  we  quote  from  the 
prospectus  issued  by  them,  as  follows: 

Poverty  is  an  object  of  pity;  sickness  and  poverty  united  seem  to  comprehend 
all  the  natural  evils  of  life.  But,  as  it  is  not  the  case  of  every  sick  person  to  be  dis- 
tressed in  circumstances,  so  there  are  not  many  persons,  thus  distressed,  whose  calamity 
it  is  to  be  frequently  or  periodically  ajfflicted  with  sickness;  whereas,  most  women  that 
marry  bear  children,  and  those  who  work  for  their  subsistence,  are,  for  a  considerable 
part  of  their  lives,  annually  disqualified  for  labor;  at  other  times  their  labor  is  but  a 
bare  support.     During  the  latter  part  of  their  pregnancy,  and  the  time  of  their  lying-in, 

*By  J.  J.  Taylor,  M.  D. 


80  HYGIENE 

the  needy  family  is  wholly  taken  up  in  attendance  upon  them,  and  the  joys,  natural 
at  such  a  season,  are  suppressed  by  the  wants  which  surround  them.  Or,  if  they  be 
destitute  of  this  attendance,  how  great  is  the  hazard  that  the  helpless  mother,  or  the 
child,  or  perhaps  both,  may,  by  their  deaths,  become  melancholy  instances  of  the  evils 
of  real  poverty. 

They  [the  governors]  allow,  that  every  fellow  creature  in  distress  is  an  object  of 
compassion,  even  though  that  distress  is  ever  so  apparently  the  consequence  of  their 
vices.  Nevertheless,  as  members  of  society,  they  think  they  should  not  be  justified, 
without  the  sanction  of  the  legislature,  in  receiving  such  objects: 

First,  because  the  legislature  has  considered  the  persons  in  question  as  criminal; 
has  rendered  them  liable  to  punishments,  and  has  declared  their  offspring  illegitimate; 
on  purpose,  no  doubt,  to  discourage  the  vices  of  individuals,  and  thereby  preserve  the 
good  order  of  the  whole. 

Secondly,  because  bastard  children  gain  a  settlement  in  the  parish  where  they 
are  born;  they  think  therefore  they  should  be  an  act  of  injustice  to  the  parish,  in 
which  the  hospital  is  situated,  in  bringing  upon  it  the  incumbrance  of  these  children, 
which,  in  a  course  of  years,  might  accumulate  to  a  very  great  number.  To  prevent 
the  like  incumbrance  upon  the  parish  (as  all  other  children,  whose  parents'  settlements 
are  not  known,  obtain  a  settlement  in  the  parish  where  they  are  born)  it  has  been  the 
custom,  before  admission  of  the  patient,  to  require  an  affidavit  of  the  time  and  place 
of  her  marriage,  and  of  the  place  of  settlement  of  the  husband  or  wife,  in  order  that 
the  parish  might  be  enabled,  should  there  be  occasion,  to  pass  the  children  to  that 
place  of  settlement. 

Similar  to  this  is  an  institution  established  in  Philadelphia  in  1837,  by  Dr.  Jonas 
Preston,  bearing  the  name  of  the  Preston  Retreat.  His  purpose  is  well  expressed 
in  the  following  extract  from  his  last  will  and  testament. 

It  has  long  been  my  opinion  that  there  ought  to  be  a  lying-in  hospital  in  the  city 
of  Philadelphia  for  indigent  married  women  of  good  character,  distinct  and  uncon- 
nected with  any  other  hospital,  where  they  may  be  received  and  provided  with  proper 
obstetric  aid  for  their  delivery,  and  with  suitable  attendance  and  comforts  during  the 
period  of  weakness  and  susceptibility  which  ensues,  continuing  ordinarily  about  four 
weeks.  I  have  no  doubt  that  there  is  often  much  suffering  and  loss  of  life  in  such  cases 
from  the  effects  of  ignorance  and  destitution,  and  I  think  an  establishment  for  affording 
the  required  assistance  well  deserves  a  place  among  the  numerous  charities  which 
attest  the  Christian  philanthropy  that  characterizes  Philadelphia.  Under  this  con- 
viction, and  to  contribute  what  may  be  in  my  power  to  supply  the  want,  with  a  firm 
belief  that  our  Blessed  Lord  will  cause  the  work  to  prosper,  so  that  the  needy  shall  not 
always  be  forgotten,  nor  the  expectations  of  the  poor  perish  forever,  I  do  hereby  give, 
devise,  and  bequeath,  etc. 

The  Preston  Retreat  exists  to-day  as  one  of  the  model  institutions  of  the 
kind  in  the  w^orld,  although  not  one  of  the  largest. 

A  class  of  institutions  v^hich  breathe  more  truly  the  spirit  of  Christian 
charity  are  those  which  open  their  doors  to  married  women  and  unfortunate 
single  women  alike.  A  fine  example  of  such  an  institution  is  the  Maternity 
Hospital  of  Philadelphia.  The  spirit  of  this  special  work  is  excellently 
shown  by  the  following  extracts  from  their  proceedings : 

"  The  object  of  this  hospital  as  set  forth  in  its  charter  is  the  care,  nurture, 
and  maintenance  of  destitute  women,  married  or  single,  during  childbirth 


MATERNITIES  81 

or  whilst  suffering  from  diseases  peculiar  to  their  sex;  of  children  born  of  their 
bodies,  either  whilst  in  the  care  of  the  corporation  or  surrendered  to  it  after 
birth;  the  providing  for  the  spiritual  and  temporal  welfare  of  such  women 
and  children  either  within  or  outside  of  the  institution,  as  well  as  the  care  and 
boarding  of  women  and  children  for  compensation." 

Most  of  the  founders  had  been  previously  connected  with  the  obstetrical 
staff  of  the  Philadelphia  Hospital,  and  all  were  familiar  with  the  fact  that  not 
infrequently  young  unmarried  girls  were  found  in  the  obstetrical  ward,  where 
they  had  gone  to  be  delivered  of  their  illegitimate  children.  As  these  girls, 
often  mere  children,  were  neither  vicious  nor  depraved,  it  seemed  cruel  to 
compel  them  to  be  exposed  to  the  degrading  effects  of  the  associations  and  the 
publicity  which  must  necessarily  follow  a  prolonged  residence  in  a  city  alms- 
house. 

As  a  careful  search  among  the  then  existing  institutions  revealed  the  fact 
that  there  was  no  place  in  the  city  of  Philadelphia,  or  the  state  of  Pennsyl- 
vania, outside  of  the  county  almshouse,  where  an  unmarried  woman  could  be 
taken  care  of  during  the  period  of  her  confinement,  it  was  then  determined 
to  create  such  an  institution. 

From  the  very  beginning  the  work  of  the  institution  was  the  subject  of 
heated  controversy.  By  many  well-meaning  persons  it  was  contended  that 
the  mere  fact  that  such  a  refuge  was  known  to  exist  would  tend  to  increase  the 
amount  of  illegitimacy  and  even  act  as  an  incentive  to  vice.  Many  indignant 
protests  were  sent  to  the  board,  and  individual  pressure,  as  well  as  public 
opposition,  was  brought  to  bear  upon  the  members.  Fully  convinced,  how- 
ever, of  the  real  necessity  for  such  a  charity,  and  trusting  to  the  ultimate 
triumph  of  broader  and  more  humane  views,  the  founders  of  the  hospital 
persisted  in  their  labors  and  the  struggle  for  existence  began. 

Since  the  admission  of  the  first  patient  in  1873,  9,693  applications  for 
admission  have  been  made,  and  3,288  women  have  been  confined  in  the 
hospital.     Of  these,  36  died,  a  mortality  from  all  causes  of  1.1  per  cent. 

The  justice  of  their  position  is  further  argued  in  the  following  quotation 
from  the  thirty-fifth  annual  report: 

The  commission  of  sin  must  be  prevented,  the  weakness  of  the  frail  girl  or  woman 
strengthened,  the  saving  of  poor  girls  "subjected  to  the  influence  of  man's  examples 
and  the  teachings  of  evilly  disposed  persons,"  leading  to  vice,  poverty,  or  crime, 
effected  through  the  instrumentalities  of  institutions  like  the  Maternity  Hospital. 

The  continued  operations  of  our  hospital  prove  the  necessity  of  its  existence,  as  a 
place  of  refuge  for  those  who  seek  admission  to  its  portals,  where  they  find  not  only 
physical  help,  careful  nursing,  and  nurture,  but  loving  counsel,  moral  uplifting,  and 
honest  effort  to  help  them  physically,  mentally,  and  morally. 

We  cannot  too  often  repeat  that  we  do  not  offer  shelter  as  an  extenuation  of  the 
sin  committed,  that  we  do  not  encourage  evildoers,  but  we  do  have  the  compassion 
and  pity  to  attempt  the  strengthening  of  the  weak,  the  care  of  the  helpless,  the  pro- 
tection of  the  suffering,  and  the  reform  of  the  sinner.  With  all  the  efforts  being  made 
to  reform  the  delinquent,  the  convicted  criminal,  and  to  substitute  for  the  law  of  re- 
venge and  vindictiveness  the  law  of  love,  should  we  hesitate  to  evidence  that  love  for 
the  poor  girl,  in  the  extremity  of  her  suffering,  and  for  the  helpless  babe,  surely  not 
responsible  for  the  error  which  has  brought  it  into  existence?     God  helping  us,  we 


82  HYGIENE 

purpose  to  continue  our  work,  not  only  as  efficiently  as  we  have  done  it  in  the  past, 
but  even  more  efficiently,  more  effectively,  and  to  that  end  we  invite  the  helpful  co- 
operation of  the  charitable  and  benevolent  public. 

Our  statistical  report  is  both  sad  and  satisfactory.  Sad  to  find  a  little  mother  of 
twelve  years,  another  of  fourteen,  four  of  fifteen,  seven  of  sixteen,  twelve  of  seventeen, 
thirty-one  of  eighteen,  nineteen  of  nineteen,  and  eleven  of  twenty,  making  eighty-six, 
or  more  than  fifty  per  cent  of  our  patients  who  became  mothers  during  their  minority; 
satisfactory,  that  out  of  a  hundred  and  sixty-eight  patients  delivered  since  October 
1, 1907,  only  one  died  from  a  septic  cause  and  none  from  a  non-septic. 

We  quote  these  reasons  in  full  as  being  the  best  expression  of  the  argu- 
ment that  could  be  given. 

One  of  the  greatest  institutions  of  this  kind  is  the  Lying-in  Hospital  of 
the  city  of  New^  York.  This  institution  was  established  in  1798  by  the  Society 
of  the  Lying-in  Hospital  of  New  York  City,  at  the  instance  of  Dr.  David 
Hosack.  Its  magnificent  building  is  one  of  the  best  equipped  maternity 
hospitals  in  the  world.  It  cares  for  more  cases  than  any  other  institution  of 
the  kind  in  America. 

The  general  purpose  of  all  these  maternity  hospitals  is  primarily  to 
supply  facilities  for  the  comfort  and  safety  of  poor  women  during  their  period 
of  confinement.  Incidental  to  this,  however,  they  supply,  by  their  perfect 
organization  and  equipment,  the  means  by  which  the  most  advanced  ideas  in 
the  science  and  art  of  obstetrics  may  be  put  into  practice  and  still  further 
developed.  Thus  they  have  been  the  means  of  advancing  the  practice  of 
obstetrics  and  of  reducing  very  greatly  the  mortality  from  the  various  acci- 
dents and  diseases  incident  to  motherhood.  The  various  problems  relating 
to  the  care  of  the  woman's  health  previous  to  confinement,  and  the  causes  and 
prevention  of  eclampsia,  puerperal  infection,  and  the  various  other  dangers  of 
the  confinement  period,  can  all  be  worked  out  most  systematically  and 
thoroughly  in  such  an  institution,  where  the  conditions  can  be  the  best  for  all 
patients  and  where  a  thorough  study  of  each  case  may  be  made.  The  results 
of  these  studies  advance  the  practice  of  obstetrics  in  private  as  well  as  hospital 
work.  Also,  they  supply  the  means  of  instruction  to  thousands  of  phy- 
sicians, medical  students,  and  student  nurses. 

A  large  part  of  the  work  of  these  institutions  consists  in  the  attendance 
upon  parturient  women  in  their  own  homes  by  students  and  visiting  physicians 
from  the  maternities.  Nurses  are  also  supplied  in  a  similar  manner  to  the 
patients  in  their  own  homes. 

In  the  period  before  our  knowledge  of  sepsis  as  the  cause  of  puerperal 
fever,  lying-in  hospitals  had  some  very  sad  experiences. 

These  diseases,  once  getting  established  in  a  large  institution,  made  it 
a  veritable  pesthole.     The  following  facts  will  give  some  idea  of  the  troubles 
which  these  institutions  went  through. 

In  1875  the  International  Congress  of  Physicians  at  Brussels  resolved: 

Large  lying-in  hospitals  ought  to  be  abolished.  They  ought  to  be  replaced  by 
small  institutions  with  separate  rooms. 

There  ought  to  be  a  house  for  occasional  use  in  the  neighborhood  of  the  estab- 
lishment, having  an  entirely  different  administration  and  different  physicians. 

All  this  was  to  avoid  puerperal  sepsis. 


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THE    LYING-IN    HOSPITAL,    SECOND    AVENUE,    17TH    AND    18TH 
STREETS,    STUYVESANT    SQUARE,    NEW    YORK 


MATERNITIES  83 

In  1856Tarnier,  of  Paris,  made  elaborate  investigations  (aroused  by  the 
high  mortality  rate  in  the  Paris  Maternity  Hospital),  and  he  found  mortality 
in  private  houses,  1  in  322;  mortality  in  maternal  hospitals  1  in  19;  Le  Fort 
(Des  Maternites,  Paris,  1866,  1,  p.  84),  estimating  statistics  for  nearly  two 
million  confinements,  found  deaths  in  hospitals,  1  in  29;  deaths  outside  of 
hospitals,  1  in  212. 

Matthews  Duncan  ("Mortality  of  Childbed  and  Maternity  Hospitals," 
Edinburgh,  1871),  seriously  called  these  figures  in  question  and  said:  "With 
our  great  registering  machinery  all  at  work,  we  cannot  find  out  what  is  the 
mortality  of  childbed  in  London." 

Henry  J.  Garrigues,  M.D.,  of  New  York  (Trans.  Amer.  Gyn.  Society, 
1877),  says  (p.  600):  "  If  we  leave  out  the  exceptional  results  of  prominent 
obstetricians,  in  wealthy  practice,  we  obtain  one  in  one  hundred,  as  repre- 
senting the  mortality  connected  with  childbed  in  large  cities,  outside  of  the 
hospitals."  He  admits  larger  figures  for  hospitals,  but  thinks  cleanliness 
and  antisepsis  would  much  modify  the  figures,  and  concludes: 

"  Lying-in  hospitals  with  a  number  of  yearly  confinements  not  exceed- 
ing a  thousand  are  not  to  be  feared,  when  they  are  properly  managed." 

These  figures  show  the  mortality  caused  largely  by  "  child-bed  fever," 
as  it  was  then  called,  but  which  is  now  known  as  puerperal  sepsis.  Since  the 
profession  has  accepted  the  facts  taught  by  Semmuelweis  and  Oliver  Wendell 
Holmes,  regarding  the  contagious  character  of  this  disease,  and  since  later 
the  principles  of  antisepsis  and  asepsis  have  been  properly  established,  the 
conditions  have  been  reversed,  and  the  mortality  in  maternities  is  less  than  in 
private  practice.  In  the  maternities  all  obstetric  procedures  are  con- 
ducted under  the  strictest  aseptic  conditions  and  infection  is  so  rare  as  to  be 
almost  a  thing  of  the  past. 

The  maternities  thus  far  considered  are  of  a  public  character  conducted 
for  a  purely  philanthropic  purpose  and  of  undoubted  legal  existence  and 
practice.  However,  it  may  readily  be  seen  that  the  private  care  of  women  in 
confinement  is  a  matter  which  easily  lends  itself  to  commercial  exploitation. 
Many  establishments  for  this  purpose  have  been  conducted,  the  most  of 
which  have  not  been  for  a  legitimate  purpose.  After  more  or  less  experience 
of  the  various  points  that  may  arise  in  the  conducting  of  such  establishments 
the  states  have  generally  enacted  stringent  laws  regulating  the  establishment, 
conduct,  and  inspection  of  such  enterprises.  From  the  different  state  laws 
we  select  those  of  the  state  of  Ohio  as  in  our  opinion  most  thoroughly  cover- 
ing the  requirements  of  the  subject. 

LAWS  OF  OHIO  REGARDING  MATERNITY  BOARDING  HOUSES  AND 

LYING-IN  HOSPITALS 

10  regulate  the  establishment,  maintenance,  and  inspection  of  maternity  boarding 
houses  and  lying-in  hospitals 
Section  1.  [Definition  of  maternity  boarding  house  or  lying-in  hospital;  nurses.\ 
Whoever  for  hire,  gain,  or  reward,  receives,  cares  for,  or  treats  within  a  period  of  six 
months,  more  than  one  woman  during  pregnancy,  or  during  or  after  delivery,  except 
women  related  by  blood  or  marriage;  or  whoever  for  hire,  gain,  or  reward  has  in  his 
custody  or  control  at  any  one  time  two  or  more  infants  under  the  age  of  two  years, 


84  HYGIENE 

unattended  by  parents  or  guardians,  for  the  purpose  of  providing  them  with  care,  food, 
and  lodging,  except  infants  related  to  him  by  blood  or  marriage,  shall  be  deemed  to 
maintain  a  maternity  boarding  house  or  lying-in  hospital.  Provided,  however,  that 
nothing  herein  shall  be  construed  to  prevent  a  nurse  from  practicing  her  profession 
under  the  care  of  a  physician  in  the  home  of  a  patient,  or  in  a  regular  hospital  other 
than  a  lying-in  hospital.     [O.  L.,  v.  99,  p.  13.] 

Sec.  2.  [Licenses;  what  contained  in  license;  limit  of  number;  inspection.] 
The  state  board  of  health  shall  have  the  power  to  grant  licenses  to  maintain  maternity 
boarding  houses  and  lying-in  hospitals.  Every  application  therefor  shall  first  be  ap- 
proved by  the  board  of  health  of  the  city,  village,  or  township  in  which  such  maternity 
boarding  house  or  lying-in  hospital  is  to  be  maintained.  Such  license  shall  be  granted 
for  a  term  not  exceeding  one  year,  shall  state  the  name  of  the  licensee,  the  particular 
premises  in  which  the  business  may  be  carried  on,  the  number  of  women  and  infants 
that  may  be  boarded,  treated,  or  maintained  there  at  any  one  time,  and,  if  required 
by  the  board  of  health  of  the  city,village,  or  township  in  which  such  maternity  boarding 
house  or  lying-in  hospital  is  located,  it  shall  be  posted  in  a  conspicuous  place  on  the 
licensed  premises.  No  greater  number  of  women  and  infants  shall  be  kept  at  one 
time  on  the  premises  than  is  authorized  by  the  license,  and  no  women  or  infants  shall  be 
kept  in  a  building  or  place  not  designated  in  the  license.  A  record  of  license  issued 
shall  be  kept  by  the  state  board  of  health,  v/hich  shall  forthwith  give  notice  to  the 
board  of  health  of  the  city,  village,  or  township  in  which  the  licensee  resides  of  the 
granting  of  such  license  and  of  the  terms  thereof.  The  state  board  of  health  and  the 
board  of  health  of  cities,  villages,  or  townships  shall  annually,  and  may,  at  any  time 
visit  and  inspect  or  designate  a  person  to  visit  and  inspect  premises  so  licensed.  [O.  L., 
V.  99,  p.  13.] 

Sec.  3.  [Revocation  of  license.]  The  state  board  of  health  may  revoke  such 
license  in  its  discretion  where  any  provision  of  this  act  is  violated,  or  in  any  case  where 
in  the  opinion  of  the  state  board  of  health  such  maternity  boarding  house  or  lying-in 
hospital  is  being  maintained  without  regard  to  the  health,  comfort,  or  morality  of  the 
inmates  thereof,  or  without  due  regard  to  sanitation  and  hygiene.  The  state  board  of 
health  shall  note  such  revocation  upon  the  face  of  the  record  thereof  and  shall  give 
written  notice  of  such  revocation  to  the  licensee  by  delivering  the  notice  to  him  in 
person  or  by  leaving  it  on  the  licensed  premises,  and  shall  forthwith  notify  the  board 
of  health  of  such  city,  village,  or  township  in  which  such  maternity  boarding  house 
or  lying-in  hospital  is  situated.     [O.  L.,  v.  99,  p.  14.] 

Sec.  4.  [Reporting  births.]  Every  birth  which  takes  place  in  such  maternity 
boarding  house  or  lying-in  hospital  shall  be  attended  by  a  legally  qualified  physician, 
who  shall  forthwith  reportthefact  of  such  birth  to  the  board  of  health  of  the  city,  village, 
or  township  in  which  such  maternity  boarding  house  or  lying-in  hospital  is  located. 
[O.  L.,  v.  99,  p.  14.] 

Sec.  5.  [Records  to  be  kept;  adopting  children.]  Every  person  holding  such 
license  shall  keep  a  record  in  a  form  to  be  prescribed  by  the  state  board  of  health 
wherein  he  shall  enter  the  name  and  address  of  the  physician  who  attended  at  any  birth 
which  may  take  place  in  such  house  or  hospital,  or  any  infant  who  may  be  sick,  and  the 
name,  age,  and  sex  of  all  children  born  on  the  premises  or  brought  thereto,  and  also 
the  name  and  age  of  every  child  who  is  given  out,  adopted,  or  taken  away  to  or  by  any 
person,  together  with  the  name  and  residence  of  the  peison  so  adopting  or  taking  away 
such  children;  and  within  twenty-four  hours  after  such  child  is  given  ovit  or  taken 
away,  shall  cause  a  correct  copy  of  the  record  relating  thereto  to  be  sent  to  the  board 
of  health  of  the  city,  village,  or  township  wherein  such  house  or  hospital  is  located. 
[O.  L.,  V.  99  p.  14.] 


MATERNITIES  85 

Sec.  6.  [Notice  in  case  of  death;  coroner's  inquest;  when  necessary.]  Every 
person  licensed  as  aforesaid  shall,  immediately  after  the  death  of  any  inmate  of  such 
boarding  house  or  lying-in  hospital,  whether  a  woman  or  an  infant  born  therein  or 
brought  thereto,  cause  notice  thereof  to  be  given  to  the  board  of  health  of  the  city, 
village,  or  township  in  which  such  house  or  hospital  is  located,  and  such  board  of 
health  shall  immediately  call  the  coroner  of  the  county  in  which  said  person  died  to 
hold  an  inquest  on  the  body  of  such  person,  unless  a  certificate  under  the  hand  of  a 
legally  qualified  physician  is  produced  to  said  board  of  health  by  the  licensee  that  such 
physician  had  personally  attended  and  examined  the  person  so  dying,  and  also  specify- 
ing the  cause  of  death,  and  said  board  of  health  is  satisfied  that  there  is  no  ground  for 
holding  an  inquest.     [O.  L.,  v.  99,  p.  14.] 

Sec.  7.  [State  board  of  health  to  furnish  books  for  records.]  Every  license  shall  be 
entitled  to  receive  gratuitously  from  the  state  board  of  health  a  book  of  forms  for  the 
registration  and  record  of  persons  received  into  such  home  or  hospital.  The  book 
shall  contain  a  printed  copy  of  this  act.     [O.  L.,  v.  99,  p.  IS.] 

Sec.  8.  [Inspection.]  It  shall  be  lawful  for  the  officers  and  authorized  agents  of 
the  state  board  of  health  and  the  boards  of  health  of  the  cities,  villages,  or  townships 
in  which  such  licensed  premises  are  located  to  inspect  such  house  or  hospital  at  any 
time  and  examine  every  part  thereof,  and  to  call  for  and  examine  the  records  which  are 
required  to  be  kept  by  the  provisions  of  this  act,  and  to  inquire  into  all  matters  concern- 
ing such  house  or  hospital  and  the  inmates  thereof,  and  it  shall  be  the  duty  of  the 
licensee  to  give  all  reasonable  information  to  such  persons  making  the  inspection,  and 
to  afford  them  every  reasonable  facility  for  viewing  and  inspecting  the  premises  and 
seeing  the  inmates  thereof.     [O.  L.,  v.  99,  p.  15.] 

Sec.  9.  [Adoption  of  children.]  No  child  under  two  years  of  age,  whether 
inmate  of  such  house  or  hospital,  or  born  therein  or  brought  thereto,  or  otherwise, 
shall  be  given  out  for  adoption,  except  by  and  with  the  consent  of  a  charitable  organi- 
zation, society,  or  institution  having  the  care  of  children  under  its  control  duly  in- 
corporated under  the  laws  of  the  state  of  Ohio  or  juvenile  court.     [O.  L.,  v.  99,  p.  15.] 

Sec.  10.  [Placing  child  for  hire,  gain,  or  reward.]  No  parent  or  guardian  shall 
give  to  any  person  an  infant  under  two  years  of  age  for  the  purpose  of  placing  it  for 
hire,  p;ain,  or  reward  under  the  permanent  care  and  control  of  another  person;  and 
no  person,  for  hire,  gain,  or  reward  shall  receive  such  infant  for  the  purpose  of  placing 
it  under  the  permanent  care  and  control  of  another.  The  provisions  of  this  section 
shall  not  apply  to  any  charitable  organization,  society,  or  institution,  incorporated 
under  the  laws  of  the  state  of  Ohio,  or  any  of  the  officers  or  agents  thereof.  [O.  L., 
V.  99,  p.  15.] 

Sec.  11.  [Secrecy  of  records!]  No  officer  or  authorized  agent  of  the  state  board 
of  health  or  the  boards  of  health  of  the  cities,  villages,  or  townships  where  such  licensed 
homes  or  hospitals  are  located,  or  any  keeper  of  such  house  or  hospital,  shall  divulge 
or  disclose  the  contents  of  the  records,  or  any  of  the  particulars  entered  therein,  except 
upon  inquiry  before  a  court  of  law,  or  at  a  coroner's  inquest  or  before  some  other  com- 
petent tribunal,  or,  in  the  case  of  such  officer  or  authorized  agent  or  keeper  of  such 
house  or  hospital  for  the  information  of  the  state  board  of  health  or  the  board  of  health 
of  the  city,  village,  or  township  in  which  said  house  or  hospital  is  located.  [O.  L., 
V.  99,  p.  15.] 

Sec.  12.  [Offering  inducements^  It  shall  be  unlawful  for  any  person  licensed 
as  herein  provided  to  advertise  that  he  will  adopt  children,  or  to  hold  out  inducements 
to  parents  to  part  with  their  offspring;  and  when  such  children  are  transferred  by  their 
parents,  or  are  given  out  for  adoption  to  other  persons,  such  transfer  shall  be  with  the 


86  HYGIENE 

knowledge  and  consent  of  a  charitable  organization,  society,  or  institution,  duly  in- 
corporated under  the  laws  of  the  state  of  Ohio,  or  juvenile  court.     [O.  L.,  v.  99,  p.  16.] 

Sec.  13.  [License.]  No  person  shall  maintain  a  maternity  boarding  house  or 
lying-in  hospital,  as  defined  in  Section  1  of  this  act,  unless  licensed  thereto  by  the  state 
board  of  health.     [O.  L.,  v.  99,  p.  16.] 

Sec.  14.  [Relationship.]  In  any  prosecution  under  the  provisions  of  this  act, 
a  defendant  who  relies  for  defense  upon  the  relationship  of  any  said  women  or  infants 
to  himself,  shall  have  the  burden  of  proof  thereof.     [O.  L.,  v.  99,  p.  16.] 

Sec.  is.  [Penalty.]  Any  person  who  shall  violate  any  of  the  provisions  of  this 
act  shall  be  guilty  of  a  disdemeanor,  and  upon  conviction  thereof,  shall  be  punished 
by  a  fine  of  not  more  than  three  hundred  (^300.00)  dollars,  or  by  imprisonment  for 
not  more  than  one  year,  or  both.     [O.  L.,  v.  99,  p.  16.] 

In  all  of  our  large  cities  there  are  many  of  these  private  maternities, 
mostly  devoted  to  caring  for  single  women  who  have  been  unfortunate  and 
whose  relatives  or  friends  are  able  to  pay  for  their  maintenance  and  care 
during  the  period  of  gestation.  We  have  visited  and  inspected  a  number  of 
such  establishments  of  the  better  class.  A  typical  establishment  of  this  kind 
is  conducted  in  the  following  manner: 

Patients  are  usually  directed  to  the  establishment  by  their  family  phy- 
sician or  lawyer.  They  are  received  in  the  house,  usually  before  their  con- 
dition of  pregnancy  is  manifest  to  the  casual  observer,  maintain  their  resi- 
dence there  until  after  their  confinement  and  they  are  sufficiently  well  to 
return  home.  A  uniform  charge  is  made  covering  all  cost  of  board  and 
services.  When  the  child  is  born,  the  mother  is  not  allowed  to  see  it,  so  as 
not  to  become  in  any  way  sentimentally  attached  to  it.  It  is  separately  cared 
for  until  called  for  by  some  family  who  wishes  to  adopt  it.  Statements  made 
to  the  writer  by  physicians  in  charge  of  these  institutions  indicate  that  there 
are  more  applications  from  respectable  families  for  these  infants  than  they  are 
able  to  supply.  They  also  state  that  they  follow  up  the  infants  and  assure 
themselves  that  they  are  properly  cared  for.  The  mother  returns  to  her  home 
after  her  recovery,  and  her  acquaintances  are  not  aware  of  the  trouble  through 
which  she  has  passed.  As  nearly  all  of  the  cases  are  first  offenses  in  which 
a  trusting  young  girl  has  been  led  astray,  this  method  of  treating  them  enables 
them  to  resume  their  place  in  the  society  of  their  home  community.  The 
physicians  who  have  followed  them  up  state  that  they  almost  invariably  lead 
a  correct  life  thereafter,  having  been  thoroughly  frightened  and  warned  by 
their  bitter  experience. 

In  contrast  to  this  is  the  practice  of  some  other  institutions  which  require 
the  young  mother  to  nurse  her  child  and  take  it  with  her  when  she  leaves  the 
institution.  This,  it  will  be  seen,  is,  to  say  the  least,  no  better  for  the  child, 
while  it  fastens  upon  the  young  mother  the  burden  which  requires  almost 
superhuman  efforts  to  bear.  The  vast  majority  of  young  women  so  treated 
lead  a  miserable  existence  either  as  a  misanthropic  recluse  or  in  a  life  of 
prostitution. 


MATERNITIES  87 

Thus  far  we  have  dealt  with  maternities  of  an  absolutely  legal  char- 
acter and  doing  a  legitimate  work.  Unfortunately  there  are  institutions 
which  are  without  legal  existence  and  are  devoted  to  criminal  practices  — 
abortion  and  infanticide.  As  it  is  a  matter  for  the  department  of  justice  of 
each  city  to  ferret  out  such  places  and  terminate  their  existence,  there  seems 
to  us  to  be  no  special  advantage  in  entering  fully  into  a  discussion  of  them  in 
this  connection. 

In  the  report  of  the  society  of  the  Lying-in  Hospital  of  the  city  of  New 
York  we  find  the  following  table  of  the  wages  per  week  of  the  husbands  of 
the  patients  treated  therein: 

;^2.00 3 

3.00 41 

4.00 102 

5.00 292 

6.00 475 

7.00 453 

8.00 709 

9.00 401 

10.00 877 

11 .00 90 

12.00 530 

13.00 78 

14.00 99 

15.00 145 

Over  ^15 81 

Among  the  occupations  of  the  husbands  we  find  that  those  connected 
with  the  tailoring  trade  far  outnumber  all  the  other  occupations  put  together. 
These  workers,  not  being  properly  organized,  are  subject  to  the  inflexible 
laws  of  supply  and  demand  of  labor,  and  hence  the  most  distressing  sweat- 
shop conditions  prevail. 

Some  interesting  points  picked  up  while  investigating  these  institutions: 

Almost  invariably  the  victim  despises  the  man  who  is  the  father  of  her 
child,  and  prefers  honest,  independent  work  to  a  prospect  of  marrying  him. 
Only  an  appeal  to  a  consideration  of  her  child's  welfare  leads  her  to  favorably 
consider  it. 

The  youngest  patient  of  which  we  have  record  is  twelve  years  of  age,  the 
oldest  a  shy  and  respectable  spinster  of  forty  —  her  first  and  only  ofFense,  for 
which  she  felt  deep  humiliation. 

Many  of  the  cases  of  seduction  have  occurred  entirely  within  the  family 
—  in  two  or  three  cases  the  father,  and  in  several  cases  the  brother  being  the 
author  of  the  trouble.  In  this  connection  it  is  well  to  note  that  boys  and  girls 
in  the  family  should  not  be  allowed  to  sleep  together  after  they  reach  the  age 
of  observation. 

It  seems  that  the  brother  in  law  is  a  most  dangerous  associate.     He  is 


88  HYGIENE 

allowed  greater  familiarity  than  other  men,  and  the  relationship  not  being  a 
blood  tie,  he  carries  the  same  magnetism  or  sexual  influence  as  other  men  not 
in  the  family.  From  observation  in  many  cases,  and  statistics  of  many  in- 
stitutions, it  may  be  established  that  the  brother  in  law  should  not  be  allowed 
any  more  familiarity  than  other  men. 

Cousins  are  a  grade  better  than  brothers  in  law  as  the  authors  of  young 
girls'  downfall. 

Parents  should  be  very  chary  of  sending  their  young  daughters  to  the 
city  to  earn  their  living.  If  such  a  step  becomes  absolutely  necessary,  then 
they  should  see  that  the  daughter  is  properly  established  in  a  respectable 
home  with  favorable  surroundings  and  has  an  opportunity  to  form  suitable 
church  or  other  social  connections. 

Parents  should  instruct  their  sons  just  as  thoroughly  as  they  do  their 
daughters  in  sexual  morality.  To  neglect  this  is  to  tacitly  acknowledge  that, 
while  they  care  for  the  virtue  of  their  own  daughters,  they  are  indifferent  to 
that  of  their  neighbors'  daughters. 

Mothers  should  thoroughly  instruct  their  daughters  not  to  allow  any 
affectionate  fondling  in  their  associations  with  young  men.  Where  these 
principles  are  most  strictly  followed  cases  of  seduction  are  rare. 

Incidental  to  the  study  of  maternities  comes  the  consideration  of  the 
care,  support,  and  education  of  infants  and  children  that,  for  various  reasons, 
are  left  without  the  protection  which  parents  could  give  them  in  their  homes. 
In  our  various  cities  the  foundling  hospitals,  which  take  care  of  infants  and 
other  very  young  children,  and  the  children's  aid  societies,  which  take 
charge  of  older  children,  are  doing  a  noble  work  for  these  homeless  ones. 
These  institutions  incidentally  perform  a  greater  service  for  society  at  large 
than  they  do  for  these  homeless  waifs.  These  children  exist  under  every  con- 
dition which  .would  favor  their  growing  up  as  vagrants  and  criminals  to  be  a 
burden  and  menace  to  society.  We  shall  see,  in  what  follows,  that,  instead  of 
this,  they  are  brought  up  to  a  higher  standard  of  physical,  mental,  and  moral 
training  than  is  the  average  child  in  its  parents'  home. 

We  will  take  as  an  example  the  New  York  Foundling  Hospital. 

In  a  niche  above  its  doorway  a  marble  statue  of  a  woman  holds  a  little 
child  close  to  her  breast.  Beneath  her,  through  a  swinging  door  that  has  not 
been  locked  for  forty  years,  women  pass  in  to  the  Foundling  Hospital  with 
their  babies  in  their  arms,  and  come  out  with  their  arms  empty.  A  single 
white  cradle  in  the  entr}^  of  a  bare  reception  room  receives  and  rescues  nearly 
two  thousand  babies  a  year.  Two  thousand  men  and  women  are  the  number 
of  a  village  community.  Here  in  the  home  of  deserted  children  are  the  things 
which  are  eternal, —  the  tears,  the  laughter,  and  the  joys. 

"  It  is  the  little  children  we  must  save,"  one  of  the  matrons  said.  "  We 
keep  them  from  privation,  from  cruelty,  even  fi'om  death  —  the  little  baby 
nobody  wants.  We  are  just  trying  to  give  them  their  chance.  We  hope  to 
preserve  the  mothers  from  greater  sin,  from  the  life  of  the  streets,  from  the 
doors  of  prison,  but  it  is  the  babies  that  count.     We  must  save  our  babies." 

The  foundling  hospitals  in  our  big  cities  are  charity's  efforts  to  play  the 


MATERNITIES  89 

part  of  universal  motherhood,  to  care  for  the  children  who  are  thrown  on  her 
mercy,  and  who  wiU  help  make  her  future. 

The  room  where  the  mothers  relinquish  their  babies  is  called  the  saddest 
place  in  New  York.  There  is  nothing  in  the  receiving  room  but  the  little 
cradle,  and  no  one  in  sight.  A  matron  is  alwaj'S  in  waiting  nearby.  She 
never  forces  a  mother  to  confession,  but  if  possible  persuades  her  to  tell  her 
why  she  wishes  to  desert  her  child,  and  perhaps  influences  her  not  to  give  it  up, 
but  to  begin  life  over  again.  A  mother  must  understand  that  the  choice  is 
with  her  —  the  matron  may  give  the  mother  ten  or  fifteen  minutes  in  which  to 
decide  —  but  the  choice  is  final. 

There  are  six  hundred  indoor  babies  being  cared  for  inside  the  New 
York  City  Foundling  Home.  It  is  necessary  to  board  on  the  outside  twelve 
hundred  more.  Seven  thousand  four  hundred  and  twenty-four  little  found- 
lings have  been  looked  after  in  the  past  two  years,  and  there  are  relatively  as 
many  in  Boston,  in  Chicago,  in  Philadelphia  —  in  every  large  city  of  America, 

In  Europe  there  are  an  even  greater  number  of  foundling  babies.  The 
European  states  take  charge  of  the  deserted  waifs,  but  the  mother  is  only  per- 
mitted to  bring  her  child  to  an  entrance  way,  ring  a  bell,  and  give  it  into  the 
arms  of  the  attendant  who  opens  the  door  —  and  go  away  without  a  word. 

These  foundling  hospitals  and  children's  aid  societies  care  for  the 
children  in  the  best  possible  manner  until  a  suitable  home  is  found,  where 
they  are  placed  by  adoption.  Not  only  infants  that  are  born  under  unfor- 
tunate circumstances,  but  children  whose  parents  die  or  desert  them,  are  taken 
care  of  by  these  institutions.  Many  are  adopted  by  child-loving  people  who 
go  to  the  institution  to  select  them  for  that  purpose.  Otherwise,  at  stated 
intervals  they  are  sent  to  the  rural  districts  of  our  country,  mainly  West  and 
South,  where  they  readily  find  excellent  homes.  There  are  always  more 
families  applying  for  children  than  there  are  children  in  these  institutions  to 
supply  the  demand. 

The  first  question  that  arises  in  the  mind  of  the  average  over-prudent 
person  is,  "  Are  not  these  children  the  offspring  of  desolute  or  degenerate 
parents,  likely  to  grow  up  into  undesirable  men  and  women  ?  "  In  answer 
to  that,  the  experience  has  been  almost  universally  just  the  opposite.  En- 
vironment conquers  heredity.  The  Children's  Aid  Society  of  New  York  City, 
for  example,  follows  up  its  children  until  they  are  nineteen  years  of  age, 
learning  of  their  condition  and  progress  once  or  twice  a  year.  We  give  some 
quotations  from  the  fifty-sixth  annual  report  (1908)  of  this  institution. 

The  sympathy  of  all  the  world  goes  out  to  the  orphans,  and  the  doors  of  countless 
homes  are  open  to  them.  We  have  but  to  make  it  known  that  a  little  child  needs  a 
mother,  and  our  desks  are  heaped  with  letters  from  good  people  who  wish  to  take  the 
little  one  into  their  families  on  trial  for  adoption,  promising  the  same  tender  care,  the 
same  education,  the  same  opportunities  in  life  as  to  their  very  own.  The  supply  of 
suitable  orphans  is  so  much  less  than  the  demand,  we  often  wonder  how  the  orphan 
asylums  compete  with  the  family  home,  especially  if  we  consider  the  cost.  The 
expense  of  placing  a  child  in  a  selected  family  in  the  country  is  thirty-eight  dollars. 
Compare  it  with  the  cost  of  maintaining  a  child  in  an  orphanage  and  compare  also  the 
advantages  of  family  life  with  the  institution.     All  are  kept  under  the  supervision  of 


-90  HYGIENE 

•our  agents  until  nineteen  years  of  age,  and  our  records  show  in  detail  their  develop- 
ment. Countless  romances  lie  hidden  in  these  records.  The  heroine  of  the  latest, 
a  child  deserted  by  her  parents,  was  taken  West  in  the  private  car  of  her  new  foster 
father,  with  a  trained  nurse  to  secure  her  from  childish  ills  while  traveling  to  her  new 
Jiome.     Surely  a  modern  adaptation  of  Cinderella  and  her  fairy  coach! 

NOTEWORTHY  CAREERS 

Most  of  our  wards  have  become  farmers  or  farmers'  wives.  Of  the  others  we  know 
of  the  following  careers: 

Governor  of  a  state 1  Members  of  state  legislatures 7 

Governor  of  a  territory 1  County  commissioners 3 

Members  of  Congress 2  Judge 1 

Sheriffs 2  Bankers 27 

District  attorneys 2  Merchants 22 

City  attorney 1  High  school  principals    4 

Business  clerks 460  Superintendent  of  schools 2 

Tawyers 34  Civil  engineers    3 

Physicians 17  Clergymen 24 

Postmasters 9  College  professors    2 

Railroad  officials    5  County  treasurer 1 

Railroad  men 36  Artists    2 

Real  estate  agents    10  County  recorders 2 

Journalists 15  County  auditors  3 

Teachers    82  Clerk  of  U.  S.  Senate 1 

School  principals    3 

From  careful  analysis  of  the  records  of  all  the  children  it  is  estimated  that  eighty- 
seven  per  cent  are  doing  well,  eight  per  cent  were  returned  to  New  York,  two  per  cent 
died,  one  quarter  of  one  per  cent  committed  petty  crimes  and  were  arrested,  and  two 
and  three  quarters  per  cent  left  their  homes  and  disappeared. 

An  example  of  the  startling  change  that  comes  in  the  lives  of  these  children  is  seen 
in  the  following  true  story: 

The  S children  were  devoid  of  all  moral  and  religious  training,  and  were  like 

wild  creatures  when  brought  to  us  in  1893.  The  parents  were  of  low  type,  the  father 
brutal  and  immoral,  and  at  time  of  surrendering  them  to  the  society  the  mother  said 
it  was  to  protect  them  from  the  father  who  was  about  to  be  prosecuted  for  assault. 

What  subsequently  became  of  S is  not  known,  but  the  mother  "  married  "  the 

man  D ,  who  proved  to  be  of  the  same  type  as  S .     Thus  her  only  hope  in 

life  has  been  in  her  three  children.  Her  letters  of  inquiry  about  them  have  been 
incessant  and  most  sympathetic,  and  always  contained  small  slips  of  fresh  cut  flowers. 
Finally  her  long  cherished  desire  to  see  the  children  once  more  induced  her  to  visit 
them  in  their  Western  homes.  On  her  return  she  called  at  our  office,  saying  she  had 
just  returned  from  a  visit  to  Nebraska  where  the  society  found  homes  for  the  three 
children  about  fifteen  years  ago.     She  found  them  all  well  and  of  fine  physique,  and  as 

happy  as  can  be  —  the  two  boys  are  strong,  manly  fellows.     C is  still  in  Nebraska, 

farming  at  twenty-five  dollars  a  month.  He  has  his  own  horses  and  implements,  and 
considerable  money  saved,  and  probably  soon  will  have  a  farm  of  his  own. 


MATERNITIES  91 

O is  a  college  man  and  expects  to  be  a  doctor.     He  is  a  splendid  fellow^ 

president  of  two  local  societies  and  one  of  the  most  popular  young  men  in  his  com- 
munity. 

R was  married  in  January,  and  is  living  in  Oklahoma,  her  husband  being  a 

relative  of  her  foster  mother,  who  brought  her  up.  He  is  said  to  be  a  fine,  ambitious 
young  man,  and  already  worth  about  ;^47,000. 

All  three  children  have  developed  splendidly  physically,  and  have  had  a  good 
Christian  training.  All  grew  up  in  churches  of  different  denominations,  with  the 
result  that  C is  now  an  Evangelist,  O a  Methodist,  and  R a  Baptist. 

The  mother  was  greatly  overjoyed  at  her  experience  in  the  West,  and  said  she 
could  not  believe  her  own  eyes  at  the  sight  of  her  three  children  of  the  present  day,  and, 
although  a  very  poor  woman,  she  "  feels  as  proud  as  a  millionaire." 


Chapter  VI 
PLACES  OF  AMUSEMENT  AND  OF  DISSIPATION* 

Opera  houses,  especially  in  time  of  epidemic — Actors  and  actresses  with  in- 
fectious diseases — Small  amusement  halls,  rinks,  and  dance  halls — Clubs  and  in- 
fectious diseases  —  The  hygiene  of  liquor  and  narcotic  addiction  — Prostitution  and 
what  the  general  practitioner  can  do  to  mitigate  its  evils  —  Our  duty  to  inmates  in 
behalf  of  public  safety — ^The  necessity  for  adequate  treatment  of  venereal  diseases — 
So-called  "  certificates  of  health." 

The  sanitation  of  parks. — iForest  reservations  —  Mountain  land  —  Salt  marshes  — 
Mosquitoes  in  same  —  Closing  natural  waterways  —  Artificial  lakes  and  ponds — - 
Municipal  parks  —  Parking  of  public  grounds  —  School  grounds  —  Public  playgrounds 
Amusement  parks  —  Expositions. 

The  sanitation  of  seaside  resorts. —  Boards  of  health  —  Quarantine  and  isolation 
as  applied  at  Atlantic  City  —  Food  supply  —  Sewerage  —  Garbage  —  Mosquitoes  and 
flies  —  Water  supply — Bathing  establishments  —  Hospitals — -The  death  rate. 

yPERA  houses,  especially  in  time  of  epidemic. —  In  Chapter  II  some 
reference  to  the  construction  of  opera  houses  serves  what  might  be 
here  said  upon  the  subject.  Some  of  the  states  wisely  require  that 
the  main  floor  of  such  structures  be  at  or  near  the  street  level.  This  prevents 
having  business  places  under  the  opera  house  and  allows  for  the  construction 
of  a  firm  stage  and  dressing  rooms  with  adequate  plumbing.  The  ventilation 
of  theaters  presents  some  difficulties,  but  mechanical  ventilation  engineers 
can  readily  solve  them.  All  theaters  of  any  size  should  be  fireproof  or  at 
least  "  slow  burning." 

In  timie  of  serious  epidemic  it  has  been  customary  for  the  civil  or  the 
health  authorities  to  close  the  opera  houses  and  other  places  of  public  gather- 
ing for  a  short  tim.e  and  to  fumigate  and  disinfect  well  before  opening  to  the 
public  again,  and  even  then  there  are  restrictions  as  to  the  patronage.  The 
wisdom  of  such  a  course  is  not  debatable.  The  boards  of  health  usually 
look  after  the  matters  concerning  the  opera  houses,  but  in  small  places  having 
no  capable  board  it  morally  devolves  upon  the  physicians  to  exact  of  all 
places  of  amusement  proper  care  in  sanitary  matters,  but  to  do  so  with  tact 
and  by  sensible  argument.  The  hangings  and  wood  construction  that  are 
inflammable  and  that  harbor  disease  germs  should  be  done  away  with  and 
there  should  be  some  adequate  regulations  as  to  ventilation,  clean  floors,  and 
expectoration. 

Several  years  ago  I  sent  to  our  local  isolation  hospital  five  smallpox 
cases  who  had  contracted  the  disease  from  a  man  seated  in  the  vicinity,  and 
who  had,  as  one  of  the  patients  described  him,  "  bumps  all  over  his  forehead." 
Audience  rooms  are  apt  to  be  overheated  and  be  charged  with  the  products  of 
respiration,  thus  reducing  the  power  of  resistance  to  infection.  In  an  afflic- 
tion like  smallpox  the  period  of  incubation  is  relatively  short  and  the  onset 
intense  and  we  can  readily  trace  the  source  of  infection;  but  in  diseases  like 

*By  J.  Harvey  Miller,  M.D. 


J,  ^'  /  /  /  /  1  1  I 


I  I  ,1  i^rrrr^^ 


SOME    HARRISiU  KG    PARK    VIEWS 
LILY    POND    AT    THE    WATER    WORKS    PARK 
AUTOMATIC    SANITARY    SPILL-WAY    AT    DAM,    WILDWOOD    PARK 
THE    RIVERSIDE    PARKWAY 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  93 

tuberculosis  the  period  of  incubation  of  which  is  more  uncertain  and  the  onset 
less  decided  it  is  harder  to  trace,  but  it  is  believed  that  many  infections  result 
in  public  gatherings  of  various  kinds. 

Whilst  meager  Phthisis  gives  a  silent  blow; 
Her  stroaks  are  sure  but  her  advances  slow. 
No  loud  alarms  nor  fierce  assaults  are  shown; 
She  starves  the  fortress  first,  then  takes  the  town. 

—  Garth's  Dispensary,  1699, 

The  advances  in  professional  and  lay  education  in  sanitary  matters  is  no- 
where better  shovv^n  than  in  the  toilet  accessories  of  theaters  and  other  public 
buildings  and  open  freely  to  all  patrons.  The  "penny  in  the  slot"  devices 
for  vending  toilet  paper,  paraffined  drinking  cups,  and  antiseptic  paper  aprons 
for  commode  use  are  to  be  commended.  In  the  chapter  upon  public  build- 
ings the  regular  and  thorough  disinfection  of  public  buildings  is  dwelt  upon. 
The  rules  there  laid  down  apply  with  the  greatest  of  force  to  theaters  and 
other  places  of  public  gathering.  Methods  of  disinfection  are  described 
in  the  chapter  devoted  to  that  subject. 

The  fact  that  actors  and  actresses  come  into  contact  with  the  hotel  people, 
the  employees  of  theaters,  and  with  persons  upon  the  trains  makes  it  very 
necessary  to  carefully  isolate  them  upon  the  first  suspicion  of  communicable 
disease.  This  is  so  well  done  that  very  little  trouble  has  occurred  with  stage 
people  so  far  as  the  dissemination  of  disease  is  concerned.  There  was  a  time 
when  actresses  were  charged  with  disseminating  venereal  diseases,  but  the 
higher  class  of  people  now  required  to  interpret  the  different  roles  and  the 
advanced  salaries  paid  have  placed  the  profession  upon  a  higher  level.  Be- 
side that,  managers  have  found  that  nights  of  revelr}'  and  excess  militate 
against  the  good  work  demanded  by  the  critics  and  the  public.  The  chorus 
is  better  paid  than  are  the  rank  and  file  of  clerks  and  factory  operatives  and 
have  less  incentive  to  evil  habits.  Women  naturally  shrink  from  the  illicit, 
and  inadequate  pay  is  the  greatest  factor  leading  them  to  such  lives.  It  is 
my  observation  that  large  stores  are  more  responsible  for  such  matters  than 
are  the  well-managed  theatrical  concerns.  Furthermore,  in  all  my  reading 
I  have  not  encountered  a  single  case  wherein  epidemics  were  traced  to 
theatrical  people. 

Small  amusement  halls,  rinks,  and  dance  halls. —  The  sanitary  faults  of 
these  places  are  vastly  greater  than  usually  inhere  to  the  larger  halls.  Poor 
construction,  deficient  cubic  capacity,  and  inadequate  arrangements  for  fire 
exits  and  ventilation  are  common  conditions.  Some  states  have  rigid  laws 
upon  the  subject.  The  recent  explosion  of  moving  picture  films  in  Pittsburg 
and  in  which  a  score  or  more  of  persons  were  seriously  hurt,  accentuates  the 
dangers  of  the  small  hall  in  which  they  are  exhibited.  Only  under  the  most 
stringent  regulations  is  it  wise  to  license  these  places.  The  larger  theaters 
have  adequate  room  for  their  proper  care  and  storage  as  well  as  exhibition. 
With  a  complete  change  in  personnel  and  good  ventilation  hourly,  the  ex- 
posure to  infection  is  strikingly  reduced  in  these  places.     It  is  the  long  play 


94  HYGIENE 

that  keeps  the  hall  closed  up  tight  until  conditions  become  bad.  Dr.  Willis 
Cummings  contributed  to  the  May,  1909,  Medical  Council  an  article  upon  the 
remedial  influence  of  good  shows  of  this  character  or  of  other  nature  that  re- 
laxes the  mind  and  are  restful.     He  says: 

It  would  pay  an  enterprising  manager  to  have  a  well-furnished,  well-organized, 
and  artistically  equipped  place  at  which  quiet  and  not  brazen  music  might  be  heard, 
where  the  highest  grade  of  pictures  the  state  of  the  art  could  produce  would  be  shown, 
where  an  admission  would  be  charged  that  would  exclude  undesirables,  thus  fur- 
nishing rest  and  pleasure. 

Such  a  description  presupposes  good  sanitary  surroundings  and  the 
enforcement  of  rules  regarding  expectoration,  etc.  The  floors  of  all  rinks  and 
dance  halls  should  be  dust  free  and  be  frequently  gone  over  with  a  proper 
floor  dressing.  Patrons  from  homes  under  quarantine  are  sometimes  found 
in  these  places,  and  it  is  well  for  the  authorities  to  be  upon  their  guard.  Con- 
tagion is  readily  carried  from  the  clasping  of  hands  by  the  skaters,  "  the  right 
hand  across  "  of  the  quadrille  or  the  whirl  of  the  waltz  or  two-step;  the 
patrons  being  in  more  danger  than  when  seated  side  by  side  in  an  audience 
room.  The  average  temperature  of  a  rink  or  dance  hall  should  not  be  above 
60  degrees  F.  and  the  ventilation  should  be  especially  well  regulated.  The 
moral  aspect  of  the  small  amusement  place  is  probably  not  so  bad  as  some 
persons  imagine.  Where  liquor  is  sold  in  them  the  case  is  apt  to  be  worse 
than  where  it  is  excluded. 

Clubs  and  infectious  diseases. —  There  are  clubs  and  clubs;  the  rich  man 
has  his,  the  middle  classes  have  theirs,  and  the  very  low  down  have  them  too. 
That  "  booze  "  is  the  magic  cement  holding  together  the  membership  of 
many  clubs  in  all  classes,  no  one  can  doubt.  True,  we  have  the  "  Thursday  " 
or  some  other  club  among  the  gentler  sex,  we  have  the  mite  society,  and  other 
church  organizations,  as  well  as  various  mutual  admiration  clubs  to  aid  good 
causes.  These  bind  people  into  reputable  membership,  but  the  sanitary 
dangers  are  forgotten.  Syphilis,  tuberculosis,  and  other  communicable 
diseases  are  no  respecters  of  person  or  social  standing.  There  should  be 
greater  care  in  these  clubs  as  to  promiscuous  kissing  among  the  women,  the 
use  of  a  common  drinking  cup,  and  the  dangers  imperilling  all  gatherings  of 
people.  Clubs  having  dormitories  should  as  promptly  report  infectious  dis- 
ease as  is  possible  because  of  the  added  danger  to  a  wider  circle  than  in  the 
home. 

The  hygiene  of  liquor  and  narcotic  addiction. —  In  the  chapter  upon  pure 
food  and  drugs  the  purity  of  liquors  is  discussed.  When  a  man  steps  up  to 
the  bar  in  a  public  saloon,  he  is  apt  to  rub  elbows  with  the  scum  of  the  earth. 
Neither  race  nor  color  is  debarred;  the  man  with  the  broken  down  syphilitic 
nose,  the  one  with  a  horrible  ozena,  the  old  sore  with  an  iodoform  dressing, 
the  fellow  who  has  tobacco  stains  on  his  chin,  all  these  and  others  no  less 
desirable  as  companions  are  there  with  you.  The  fellow  with  a  chancred  lip 
may  have  had  his  ale  from  the  same  glass  you  are  now  holding  in  your  hand, — 
true,  it  might  have  had  a  slight  rinsing  in  cold  or  luke-warm  water  just  prior 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  95 

to  your  using  it  and  allowed  to  drain  imperfectly  by  being  inverted  upon  a 
brass  or  wooden  drain.  The  most  insanitary  drinking  vessel  of  them  all  is 
the  tin  cup,  supposed  to  hold  a  ten-cent  quantity  of  beer  or  porter.  There 
is  frequently  a  circle  of  rust  near  the  rim  from  which  the  liquor  is  drunk,  a  fit 
hiding  place  for  infection.  The  "  stein  "  with  its  rough  surface  and  at  times 
its  pewter  top  cannot  be  as  readily  cleansed  as  is  the  drinking  glass  by  a  per- 
functory rinsing.  From  my  own  experience  I  know  that  a  large  percentage 
of  bartenders  are  syphilitic  and  I  also  know  that  many  have  chronic  gonor- 
rhoea, with  acute  exacerbations,  one  attack  subsiding  to  give  place  to  another. 
They  do  not  exercise  the  necessary  care  in  washing  their  hands  after  having 
dressed  an  open  sore  or  readjusted  a  d-a-b-d.  In  many  cases  they  themselves 
are  heavy  "  customers  "  of  the  goods  supplied  at  the  bar,  they  handle  all 
drinking  vessels  and  drink  from  many,  and,  with  an  imperfect  cleansing  of 
them,  pass  them  out  to  the  trade.  The  old  sawdust  spitting  box  and  the  large 
earthenware  spittoon  are  still  seen  in  country  taverns  and  very  low  down 
saloons.  The  brass  rod  usually  covered  with  verdigris  and  running  along  the 
upper  and  outer  edge  of  the  bar  is  rapidly  disappearing. 

The  up  to  date  bar  fixtures  are  at  least  to  some  extent  sanitary.  The 
highly  polished  hardwood  floor  is  more  easily  kept  clean.  The  slate  trough  upon 
the  floor  immediately  in  front  of  the  bar  for  use  as  a  cuspidor  and  a  receptacle 
for  the  froth  that  some  men  insist  upon  blowing  off^  their  mug  of  beer  is  cer- 
tainly an  improvement  upon  the  old  sawdust  box.  U  -^^  ^^i'^^s^^    M 

The  next  group  of  gentlemen  stepping  up  to  the  bar  might  ask  for 
whiskey.  The  bartender  touches  the  bottle  while  placing  it  upon  the  bar, 
the  men  in  their  order  pouring  the  quantity  they  desire  also  handled  the 
bottle,  and  it  is  again  placed  upon  the  shelf  back  of  the  bar,  to  be  passed 
around  again  and  again  —  being  handled  and  rehandled  by  unclean  hands, 
by  syphilitic  hands,  by  tuberculous  hands,  by  hands  with  surgical  dressings 
upon  them  and  at  times  with  gonorrheal  pus.  The  outside  of  the  bottle  is 
never  cleansed,  in  fact  the  paper  label  "  Trimble,"  "  Mount  Vernon,"  or 
what  not,  must  do  service  so  long  as  it  is  readable,  so  that  the  bottle  can  be 
filled  and  refilled  by  some  dollar  and  a  half  blend  from  a  barrel  in  the  cellar 
after  the  lights  are  out. 

Hotelkeepers  are  frequently  very  kind-hearted  men,  and  will  keep  in 
their  employ  individuals  who  are  actually  too  ill  to  work.  In  my  own  voting 
precinct  a  hotel  man  allowed  a  bartender  to  continue  in  employment  until  he 
became  bedfast  from  pulmonary  tuberculosis. 

Worse  than  the  dining-room  waiter's  towel  suspended  from  the  waist  is 
the  towel  we  find  suspended  from  the  bar  in  a  drinking  place.  I  have  seen 
it  used  by  the  man  with  mustache  and  beard  to  wipe  these  appendages  upon 
and  have  also  seen  it  used  to  wipe  hands  upon  by  the  individual  just  return- 
ing from  the  urinal.  Very  few  hotels  pass  you  your  glass  of  beer  as  it  was  my 
pleasure  to  drink  it  at  the  Hoffman  House,  each  individual  glass  being  upon  a 
tray  and  with  clean  napkin  accompanying  same.  The  time  is  not  far  distant 
when  the  public  will  demand  sanitary  drinking  places  and  in  which  the  uten- 
sils will  all  be  sterilized  by  boiling  water  and  the  barkeeper  alone  be  allowed 


96  HYGIENE 

to  handle  spirit  bottles  and  have  a  clean  napkin  wrapped  about  his  hand  when 
he  does  so.     Clean  paper  napkins  should  be  served  with  drinks. 

The  coils  of  piping  through  which  beer  and  porter  flow  should  be  in- 
spected by  the  health  authorities,  and  they  should  require  that  the  water- 
propelled  beer  pump  should  be  surrounded  by  fresh  and  clean  air.  The 
cellar  air  may  be  very  contaminated  and  the  pump  should  be  placed  where 
this  is  impossible. 

The  moral  evils  of  excessive  drinking  need  not  be  dvv'elt  upon  here;  they 
are  only  too  apparent  to  all.  It  is  certainly  to  be  hoped  that  some  rational 
solution  of  the  evils  that  have  crept  into  the  business  of  dispensing  alcoholic 
liquors  should  be  arrived  at  and  that  they  will  be  of  such  a  character  as  to  be 
acceptable  to  the  reasonable  man  both  in  and  out  of  the  business.  Personal 
hygiene  is  not  involved  in  this  book. 

There  is  no  hygiene  of  narcotic  addiction,  except  to  keep  away  from 
narcotics.  As  illustrative  of  the  extent  to  which  drugs  may  enslave  a  man, 
the  following  news  item  is  partially  reproduced: 

Special  dispatch  to  The  Patriot. 

Lewistown,  Sept.  27.  In  S ,  who  says  he  hails  from  Philadelphia,  local  phy- 
sicians saw  a  dope  fiend  who  by  long  odds  is  the  worst  ever. 

S informed  Dr.  W.  H.  Sweigert,  from  whom  he  obtained  an  old  hypodermic 

needle,  that  his  average  is  one  hundred  and  twenty  grains  of  morphine  and  sixty  grains 
of  cocaine  daily.  When  induced  to  remove  his  clothes  his  entire  body  was  found  to 
be  a  mass  of  punctures  incident  to  the  jab  of  the  needle.  From  the  base  of  his  collar 
bone  to  the  ankle  joints  his  skin  surface  looked  as  if  a  crude  attempt  had  been  made 
at  tattooing.  There  were  thousands  of  little  punctures,  more  than  a  score  of  these 
having  created  sores  as  large  as  a  quarter  dollar. 

The  man  is  traveling  along  the  Pennsylvania  railroad  right  of  way,  and  the  patrol- 
men have  had  a  busy  season  keeping  him  away  from  the  tracks.  Last  night  he  visited 
a  lonely  watch  box  in  the  heart  of  the  Lewistown  Narrows,  crying  like  a  child.  The 
watchman  found  that  his  needle  had  become  clogged,  and  he  was  unable  to  get  any 
of  the  dope  into  his  system.  As  soon  as  the  defect  was  remedied  he  gave  himself  a 
shot  and  ran,  laughing  like  a  school  boy,  in  the  direction  of  Mifflin. 

The  editor  takes  the  liberty  of  interpolating  at  this  point  certain  observations 
upon  the  subject  from  a  national  point  of  view.  Careful  study  of  the  temperance 
problem  justifies  the  statement  that  the  consumption  of  spirits  is  not  keeping  pace 
with  that  of  beer  and  other  malt  liquors.  The  adulteration  of  the  first  class  is  so 
notorious  that  the  consumer  is  becoming  afraid  of  them.  Furthermore,  the  large 
employers  object  to  their  men  becoming  intoxicated  and  their  stand  is  having  a  most 
healthy  influence.  Beer  is  a  city  drink  and  must  be  iced,  and  the  poor  of  the  cities 
are  using  it  in  preference  to  the  spirits  that  cost  more  and  do  not  impress  them  as 
having  a  food  value.  The  city  saloon  business  is  really  in  a  pretty  bad  way,  and  the 
profits  of  the  average  saloon  are  not  large.  There  has  been  a  great  rivalry  among  the 
brewers  to  control  saloons,  and  that  has  been  using  or  tying  up  their  capital  and 
obliging  them  to  enter  into  politics  to  keep  up  their  end  of  the  transaction.  So  long 
as  the  country  was  full  of  small  breweries  conducted  by  men  of  small  business  ability, 
this  ruinous  competition  continued,  and  is  somewhat  in  evidence  to-day. 

But  breweries  are  combining  and  the  bad  business  management  characterizing 
them  in  the  past  is  giving  way  to  a  rational  handlingof  their  interests  by  men  well  trained 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  97 

in  modern  business  methods.  In  addition  to  this,  the  people  who  now  own  the  brew- 
eries are  of  a  very  much  higher  grade  than  was  the  case  thirty  years  ago.  All  this 
tends  to  the  elimination  of  ruinous  competition  and  the  brewery  ownership  of  in- 
sanitary saloons  and  low  dives.  It  is  reasonable  to  expect  an  improvement  in  the 
saloon  business  within  a  very  few  years.  It  is  already  apparent,  and  temperance 
people  like  myself  can  afford  to  refrain  from  hysterics  and  can  help  along  in  the  general 
uplift  that  is  influencing  the  saloon  business  in  a  perfectly  natural  way  aside  from 
legislation  and  political  parties.  One  of  the  best  things  I  know  of  in  the  way  of  saloon 
reform  is  the  high  license  law  depending  upon  population  as  to  the  location  of  saloons. 
Massachusetts  and  Pennsylvania  have  such  laws,  and  thev  work  well.  Here  in  Harris- 
burg,  a  place  with  a  very  large  drinking  population,  there  is  a  section  of  the  city 
boasting  a  population  of  30,000,  and  it  has  not  one  saloon  or  hotel  license.  I  live 
in  a  central  ward  and  there  is  not  a  license  in  it.  There  are  plenty  of  places  to  get  a 
drink,  but  we  district  such  things  here. 

Local  option  is  a  big  factor,  provided  the  unit  rule  prevails.  A  ward  or  a  town- 
ship, or  even  a  borough  may  vote  for  local  option  and  enforce  it,  but  it  is  very  doubtful 
if  any  large  city  in  the  Union  is  in  position  to  absolutely  exclude  liquor.  There  is  no 
one  plan  suitable  for  the  whole  country,  and  it  is  doubtful  if  there  is  a  plan  suitable 
for  even  all  portions  of  a  large  state.  I  have  been  in  a  position  to  learn  that  religious 
considerations  do  not  influence  even  the  majority  of  church  members  when  license  or 
no  license  stands  in  the  way  of  their  business  interests.  Temperance  in  politics  has 
cut  a  sorry  figure.  Social  matters  influence  the  liquor  question  very  slightly.  It  is 
racial  and  business  affairs  that  dominate  in  the  question  aside  from  personal  appetite. 
Making  good  Americans  of  our  foreign  contingent  will  advance  temperance  but  not 
prohibition.  Business  generally  is  amenable  to  law.  Why  should  the  liquor  business 
be  an  exception  ?  If  the  courts,  the  sanitary  ofiicer,  and  the  trade  organizations  domi- 
nate a  bakery  to  its  advantage  and  the  welfare  of  the  community,  it  is  but  a  step  to  the 
saloon,  and  the  saloon  must  yield  to  the  power  of  public  opinion  and  reform  itself. 
I  would  be  in  favor  of  giving  the  liquor  interests  reasonable  time  to  correct  abuses  and 
get  in  badly  invested  money,  but  after  the  expiration  of  such  a  time  there  is  no  reason 
that  can  be  advanced  by  them  for  a  continuance  of  their  present  wretched  methods. 
The  saloon  has  no  more  right  to  violate  law  than  has  the  doctor,  and,  at  the  last 
analysis,  most  of  the  worst  features  of  the  liquor  business  are  the  direct  result  of 
violation  of  law  already  upon  the  statute  books. 

Prostitution  and  what  the  general  practitioner  can  do  to  mitigate  its  evils. — 
Webster  defines  prostitution  as  the  "  act  or  practice  of  prostituting  or  offer- 
ing the  body  to  an  indiscriminate  intercourse  with  men.  "  When  v\^e  consider 
prostitution  and  the  evils  resulting  therefrom  or  the  possibility  of  doing  away 
with  it  entirely,  "  it  is  a  condition  and  not  a  theory  that  confronts  us."  The 
moralist  may  dream  of  the  day  when  prostitution  will  be  banished  from  the 
earth;  but  the  practical  man,  the  one  who  does  more  but  dreams  less,  will  con- 
sider conditions  as  they  exist,  and  instead  of  attemptingthe  impossible  thing — 
a  complete  upheaval  of  the  social  sin  —  he  will  simply  do  what  little  he  can 
either  as  an  individual  or  as  a  member  of  a  society  organized  for  the  purpose, 
to  mitigate  the  present  evils. 

That  prostitution  dates  from  early  times  is  evident  from  Bible  history. 
"  Do  not  prostitute  thy  daughter."  Lev.  xix.  29.  The  middle  West  of  our 
country  seems  to  have  taken  the  most  rational  stand  upon  this  problem.  I 
have  read  with  much  interest  "  Social  Hygiene  vs.  The  Sexual  Plagues," 


98  HYGIENE 

issued  by  the  Indiana  State  Board  of  Health,  and  designed  to  teach  the  public 
the  dangers  of  venereal  disease.  Literature  of  this  kind,  in  simple  language, 
yet  thoroughly  scientific  and  containing  reliable  statistics,  must  be  productive 
of  much  good.  Our  youth  should  knov^  the  dangers  of  prostitution,  and 
they  should  be  informed  by  parent,  physician,  priest,  minister,  and  teacher  as 
well  as  by  proper  literature.  Dr.  Morrow^  (Jour.  A.  M.  A.,  March  4,  1905) 
urged  upon  the  Department  of  Health  of  New  York  city  the  sending  out  of 
circulars  of  warning  regarding  venereal  infection,  but  was  refused  lest  such 
information  "  might  offend  the  moral  susceptibilities  of  the  community." 
Boys  and  girls  should  not  be  allowed  to  reach  maturity  without  such  warning, 
and  it  would  come  with  especial  force  from  a  board  of  health.  Then,  if  they 
offend,  they  do  not  do  so  ignorantly. 

In  my  experience  it  is  not  the  young  man  who  is  most  responsible  for 
prostitution,  but  rather  the  older  married  men  —  usually  the  father  of  several 
children  and  the  husband  of  a  wife  whose  every  thought  is  for  the  comfort  of 
the  family.  Man  is  by  nature  a  polygamist.  Were  it  possible  for  every  man 
to  be  true  to  the  woman  he  calls  wife,  there  would  be  few  prostitutes.  The 
single  man  might  have  heard  something  of  "  sex  necessity,"  or  idle  curiosity 
might  lead  him  to  a  house  of  ill  fame,  but  his  visits  are  few  and  far  between 
compared  with  the  nights  spent  in  revelry  and  lewdness  by  the  married  men. 
Radical  measures  to  limit  prostitution  are  useless,  for,  when  unduly  oppressed, 
the  traffic  seeks  cover  and  practices  clandestinely  in  the  midst  of  respectability 
to  the  aggravation  of  morals  and  ill  health.  Properly  regulated,  there  is  a 
natural  tendency  for  prostitutes  to  segregate.  In  early  days  they  were  burned 
at  the  stake,  drowned,  scourged,  and  tortured  in  divers  ways.  Were  all  the 
prostitutes  to  be  deported  their  ranks  would  soon  be  recruited,  as  the  poly- 
gamous instinct  in  man  demands  a  supply. 

At  the  forty-fourth  annual  session  of  the  Ohio  Eclectic  State  Medical 
Association,  Jerome  D.  Dodge,  M.D.,  read  a  paper  upon  "  The  Medical 
Profession  and  Purity,"  from  which  I  quote: 

In  so  far  as  the  enlightenment  of  the  general  public  is  concerned,  the  subject 
(purity  of  the  sex  life)  has  been  strangely  neglected,  through  a  shameful  prudery, 
until  evils  of  gigantic  proportion  have  resulted.  The  times  are  ripe  for  purity  organi- 
zations. The  psychological  period  has  come  when  they  can  do  a  great  and  necessary 
work  in  reforming  our  local  and  national  life. 

The  youth  of  the  land  must  be  taught  the  dignity  and  the  true  meaning  of  the  pow- 
ers of  the  sex  life,  its  purpose,  its  proper  care,  and  its  dangers.  They  must  be  taught  not 
only  thou  shalt  not,  but,  the  why  not. 

At  a  stated  meeting  of  the  Pennsylvania  Society  for  the  Prevention  of 
Social  Diseases,  November  6,  1908,  the  important  question  was  considered, 
"  Have  our  women  and  girls  a  right  to  the  facts  regarding  social  disease  ?  It 
was  discussed  from  several  standpoints  and  the  concensus  of  opinion  was 
affirmative  and  those  qualified  to  speak  and  write  were  urged  to  do  so. 

The  New  York  State  Journal  of  Medicine,  in  a  recent  issue,  said,  under 
the  title,  "  Idle  Wives,  Unmated  Men,  and  the  Venereal  Peril  "  : 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  99 

We  have  drifted  away  from  the  happy  old  habit  of  thinking  of  the  wife  as  an  help- 
meet, to  the  habit  of  treating  her  as  a  luxury  to  be  maintained  at  a  certain  necessary 
expense,  just  as  one's  yacht  must  be  maintained.  This  is  the  state  in  which  many 
young  men  think  a  wife  wants  to  live,  and  few  young  men  can  afford  to  maintain  a 
luxurious  appurtenance  of  this  sort.  Marriage  is  postponed.  The  roaming  about  of 
unmated  men,  seeking  who  may  devour  them,  is  far  too  prevalent  and  a  great  cause 
of  the  venereal  peril. 

An  editorial  in  the  Medical  Era  of  February,  1909,  says: 

The  most  popular  movement  of  the  day  is  the  one  looking  to  the  suppression  of 
vice.  People  have  banded  together  for  the  avowed  purpose  of  throttling  all  manner 
of  vice,  their  most  aggressive  efforts  being  directed  against  immoral  sex  relations. 
Their  methods  insist  upon  a  sudden  upheaval  of  a  complex  social  system  whose  growth 
has  been  a  matter  of  many  centuries.  Among  the  means  chosen  to  bring  about  a 
healthier  moral  tone  has  been  the  closing  or  attempted  closing  of  houses  of  ill  fame. 
In  other  words,  the  old  cancer  was  rooted  up,  cut  into  a  dozen  pieces,  and  scattered, 
full  of  contamination,  in  every  direction,  a  new  nidus  of  horror  and  infection  taking 
growth  wherever  a  section  of  the  parent  body  landed.  What  a  feeling  of  horror  would 
possess  the  people  were  an  organization  to  advocate  the  elimination  of  smallpox  by 
razing  the  pest  house. 

General  Bingham,  of  New  York  city,  has  recently  said: 

It  is  high  time  for  thoughtful  people  in  this  country  to  wake  up  to  the  fact  that  law 
breaking  in  our  greater  cities  is  to  an  appalling  extent  a  safe  and  profitable  occupation, 
and  that  one  reason  for  this  condition  of  affairs  is  the  superfluity  of  laws,  many  of 
which  are  placed  upon  the  statute  books  and  among  the  ordinances  not  to  be  enforced, 
but  to  be  used  as  weapons  of  blackmail  and  graft.  There  are  laws  making  it  a  crime 
to  rent  a  house  for  prostitution,  and  there  are  laws  making  it  a  disdemeanor  to  be  a 
proprietress  or  an  inmate  of  a  house  of  ill  fame.  These  laws  had  better  be  repealed 
than  to  be  used,  as  we  have  known  them  to  be  as  a  weapon  for  personal  jealousy  or 
political  revenge,  or  their  enforcement  threatened  for  the  purpose  of  blackmail  and 
graft. 

Theodore  Roosevelt,  in  The  Outlook,  March  20,  1909,  says: 

Socialism  intends  to  do  away  with  both  prostitution  and  marriage,  which  he 
(M.  Gabriel  Deville,  a  French  socialist)  regards  as  equally  wicked,  his  method  of 
doing  away  with  prostitution  being  to  make  unchastity  universal.  Prof.  Carl  Pearson, 
a  leading  English  socialist,  states  their  position  exactly:  The  sex  relation  of  the  future 
will  not  be  regarded  as  a  union  for  the  birth  of  children,  but  as  the  closest  form  of 
friendship  between  man  and  woman.  .  .  .  Aside  from  its  thoroughly  repulsive 
character,  it  ought  not  to  be  necessary  to  point  out  that  the  condition  of  affairs  aimed 
at  would  in  actual  practice  bring  about  the  destruction  of  the  race. 

An  important  article  in  the  Medical  Council  for  May,  1909,  by  Theodore 
Schroeder,  member  of  the  New  York  and  Utah  bars,  gives  a  wealth  of  his- 
toric data  proving  that  the  early  polygamy  of  the  Morman  Church  did  not 
prevent  or  even  seriously  limit  prostitution. 

The  medical  profession  should  try  to  bring  about  the  prophecy  of  Des- 
cartes: "  If  it  is  possible  to  perfect  mankind,  the  means  of  doing  so  will  be 
found  In  the  medical  sciences."     He  should  also  consider  what  James  Foster 


100  HYGIENE 

Scott  has  said:  "  Every  individual  who  is  possessed  of  the  strongly  character- 
istic attributes  of  manhood  must  belong  either  to  the  side  which  is  in  favor 
of  purity,  or  to  the  faction  which  practices  and  advocates  sensuality.  After 
the  advent  of  puberty  a  neutral  or  indifferent  attitude  is  impossible."  The 
general  practitioner  of  loose  morals  can  do  nothing;  but  he  who  is  known  to 
be  on  the  side  of  purity  can  do  much  both  by  precept  and  by  example. 

The  medical  societies  could  do  much.  Knowledge  from  such  a  source 
would  command  the  respect  of  all.  Physicians  already  instruct  a  very  large 
number  of  people,  but  usually  not  until  they  come  to  them  as  victims  of  dis- 
ease. Dodge  has  said :  "  Occasions  arise  and  do  arise  upon  which  the  general 
practitioner  can  warn  and  admonish;  and  he  has  the  right  to  make  the  occa- 
sion if  he  sees  fit."  None  are  better  qualified  to  speak  concerning  the  ills  of 
prostitution  than  is  he.  If  there  ever  be  adequate  legislation  concerning 
prostitution,  the  knowledge  possessed  by  the  general  practitioner  must  be  a 
factor  in  framing  such  laws  and  ordinances. 

Our  duty  to  inmates  on  behalf  of  public  safety. —  Prostitution  fills  its  ranks 
principally  from  the  poor  and  ignorant  classes.  We  should  inform  them  of 
their  dangers.  There  should  be  a  medical  society  and  health  board  circular 
to  hand  to  them.  Social  purity  societies  should  be  formed  in  every  populous 
center,  and  the  physicians  should  be  active  therein.  To  illustrate  what  edu- 
cation along  a  particular  line  will  do,  I  have  had  a  number  of  patients  come  to 
me  recently  who  had  read  circulars  sent  out  by  the  anti-tuberculosis  societies, 
and  who  inquired  if  they  had  the  new  disease  called  tuberculosis.  When 
called  to  attend  inmates  we  should  not  only  give  them  adequate  treatment, 
but  should  warn  them  to  keep  in  seclusion.  We  frequently  see  gross  lesions 
of  syphillis  and  gonorrhoea  among  prostitutes,  and  are  powerless  to  prevent 
their  spreading  the  diseases.  Recently  I  prescribed  for  a  woman  from  whose 
body  there  emanated  the  odor  of  putrid  flesh,  who  had  a  series  of  syphilitic 
ulcers,  and  who  was  regularly  "  seeing  company."  She  said  to  me,  in  answer 
to  my  question,  "  Why  not,  when  nobody  complained  ?  "  Venereal  diseases 
must  be  well  treated,  and  if  so  are  curable.  In  a  prostitute?  No!  She 
cannot  remain  a  prostitute  and  follow  up  the  hygienic  and  medical  measures 
requisite  for  cure. 

Young  men  who  come  to  us  with  their  first  venereal  infection  should  be 
frankly  and  kindly  treated,  and  we  should  gain  their  confidence.  Make 
yourself  his  best  friend.  Be  gentle  in  your  admonition;  put  all  friendliness 
and  sincerity  of  heart  in  your  advice  for  future  conduct;  above  all  cure  him, 
cure  him  right,  to  stay  cured. 

So-called  "  certificates  of  health." —  Much  to  my  shame,  I  have  written 
them.  Having  practiced  medicine  for  the  past  nine  years  in  a  semi-tenderloin 
district,  some  of  my  early  experiences  took  me  among  the  "  painted  dames," 
and  upon  one  of  my  first  visits  I  saw  tacked  upon  the  wall  a  prescription 
blank  of  one  of  our  most  distinguished  and  reputable  practitioners  and  upon 

which  was  written,   "  I   have  this   day   (date)   carefully   examined 

and   find  her  free  from  venereal  disease."     Signed, M.D.      I  had 

never  seen  any  writing  of  the  kind  before,  but  have  seen  many  since,  all 


A    BOTANICAL    GARDEN,    WASHINGTON.       PhotO,  J.  A.   Kepplc 

HOUSE  OF  PUBLIC  COMFORT.     A  ncccssary  sanitary  adjunct  to  parks- 
A  PARK  MUSEUM.  _  Memorial  Hal],"Tairmount  Park,  Philadelphia 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  101 

worded  about  the  same,  both  from  this  and  other  honorable  practitioners, 
members  of  various  medical  societies.  I  have  written  and  signed  the  same 
kind  of  certificate. 

Upon  one  occasion  I  attempted  to  be  truthful  and  worded  my  certificate 
as  follows:  "  This  certifies  that  I  have  made  a  careful  examination  of  the 
genitals  and  surrounding  structures  of and  find  no  evidence  of  vene- 
real disease."  This  certificate  was  returned  to  my  office  for  explanation  and 
elucidation. 

It  is  absolutely  impossible  by  any  medical  supervision  to  guarantee  the 
health  of  a  woman  leading  a  life  of  vice. 

Any  partial  advantages  of  such  supervision  are  more  than  compensated 
by  the  increase  of  libertinism  engendered  by  a  false  sense  of  security,  so  that 
it  actually  results  in  increased  disease  among  men. 

Such  are  the  conclusions  of  Dr.  Chaufleury  and  others  who  have  enjoyed 
a  large  field  of  observation: 

Then  gently  scan  your  brother  Man, 

Still  gentler  sister  Woman; 
Though  they  may  gang  a  kemin  wrang, 

To  step  aside  is  human: 
One  point  must  still  be  greatly  dark, 

The  moving  why  they  do  it; 
And  just  as  lamely  can  ye  mark 

How  far  perhaps  they  rue  it. 

Who  made  the  heart,  'tis  He  alone 

Decidedly  can  try  us. 
He  knows  each  chord,  its  various  tone. 

Each  spring  its  various  bias; 
Then  at  the  balance  let's  be  mute. 

We  never  can  adjust  it; 
What's  done  we  partly  may  compute. 

But  know  not  what's  resisted. 

—  Robert  Burns 


Sanitation  of  Parks* 

Forest  reservations. —  This  is  a  matter  of  greater  economic  than  of 
hygienic  interest.  Ex-President  Roosevelt  and  others  gave  a  great  impetus 
to  the  important  subject  of  forest  conservation  and  the  colleges  have  been 
taking  up  the  matter.  Yale  University  grants  the  degree  of  Master  of  For- 
estry after  a  two  years'  post-graduate  course.  Harvard  practically  parallels 
this  course  in  its  Graduate  School  of  Applied  Science.  The  University  of 
Michigan  has  a  Forest  School  giving  a  post-graduate  degree  of  Master  of 
Science  in  Forestry.  Numerous  undergraduate  courses  are  given  in  the 
various  colleges  and  agricultural  schools,  in  all,  over  twenty  institutions 
offering  good  courses,  while  many  others  give  partial  lecture  courses.     Twenty- 

*By  the  Editor, 


102  HYGIENE 

seven  of  the  states  have  state  forest  officers  and  most  of  these  departments 
will  supply  literature  to  any  interested  person.  The  American  Forestry 
Association  and  the  Society  of  American  Foresters,  both  of  Washington,  have 
published  interesting  literature,  while  thirty-two  state  organizations  have 
thus  far  been  formed  to  promote  the  interest  of  forest  conservation  and  reser- 
vation. 

The  present  writer  sees  many  practical  difficulties  in  the  path  of  the  con- 
servators of  our  forests  in  this  unduly  commercialized  country.  Some  efforts 
fail  because  of  forest  fires  in  adjacent  unguarded  property.  It  is  very  hard 
to  get  the  owners  of  the  forests  to  take  any  effective  precautions  against  fire. 
The  hardest  physical  labor  I  have  ever  done  was  fighting  forest  fire.  Persons 
who  have  never  faced  such  fires  can  have  little  conception  of  how  fierce  and 
destructive  they  are.  There  are  great  areas  in  this  country  that  are  not  worth 
a  dollar  per  acre  because  they  are  covered  with  the  stumps  and  wreckage  of 
oft-repeated  fires.  They  are  no  good  as  timber  land  and  clearing  them  for 
the  plow  costs  more  than  the  game  is  worth.  The  only  use  made  of  them  is 
to  occasionally  set  up  a  movable  turpentine  still  therein.  With  intelligent 
handling,  most  of  this  land  would  eventuate  in  valuable  timber  areas,  but 
there  is  absolutely  no  hope  of  this  coming  to  pass  unless  the  state  governments 
do  the  work.  Some  of  the  railroads  are  doing  good  work  in  growing  locust 
trees  for  ties,  but  they  have  their  discouragements  because  wanton  persons 
destroy  so  many  of  the  young  trees  and  forest  fire  impends  in  any  dry  season. 

It  has  been  suggested  that  the  states  purchase  large  areas  and  enter  the 
field  of  scientific  forestry,  and  the  suggestion  is  a  good  one.  It  has  also  been 
recommended  that  the  states  make  use  of  these  areas  in  protecting  watersheds, 
housing  consumptives,  supplying  free  summer  camps  for  all  classes  of  invalids 
and  persons  desiring  a  cheap  and  hygienic  outing,  and  developing  great 
natural  parks.  This  plan  would  supply  places  of  amusement  to  great  num- 
bers of  people,  hygienic  labor  to  many  others,  and  the  revivifying  influences 
of  the  forest  to  many  who  would  be  benefited  thereby.  The  advantages  of 
the  plan  are  so  obvious  to  physicians  as  to  require  little  comment  upon  my 
part.  However,  it  particularly  impresses  me  that  the  present  methods  of 
caring  for  tuberculous  persons  involve  so  much  expense  as  to  necessarily 
limit  the  charity  of  the  states  and  municipalities  to  but  a  small  proportion  of 
the  total  number  of  cases.  Were  the  states  to  undertake  forestry  upon  a  large 
scale,  many  of  the  incipient  cases  could  engage  in  productive  labor  in  the 
forests  and  perhaps  be  sufficiently  restored  as  to  comfortably  live  and  labor  in 
these  reserves  for  many  years. 

Mountain  lands. —  The  Adirondacks  have  a  great  reputation  as  a  health- 
giving  area.  This  is  largely  because  they  have  been  exploited  and  their  ad- 
vantages developed.  In  many  parts  of  this  country  are  mountain  regions 
capable  of  being  made  quite  as  charming  and  as  hygienic  as  is  this  justly 
celebrated  region.  Mountains  are  great  conservators  of  moisture  and  they 
supply  the  head  waters  of  many  a  mighty  river.  With  good  roads  to  these 
mountains  and  pipe  lines  from  them,  the  mountain  dwellers  and  the  valley 
residents  would  both  be  benefited.      Mountains  are  great  watersheds  and 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  103 

the  time  is  coming  when  the  states  will  be  obliged  to  exercise  a  greater  super- 
vision over  them.  As  places  of  amusement  they  are  much  abused  and  the 
indiscriminate  defilement  of  head  waters  by  careless  campers  should  be 
stopped.  Boards  of  health  should  be  especially  careful  as  to  typhoid  cases 
occurring  in  elevated  regions.  Hay  fever  sufferers  would  appreciate  moun- 
tain regions  under  such  supervision  as  would  render  them  suitable  for  resi- 
dence by  sufferers  with  this  ailment.  (See  "  Rural  Resorts,"  in  the  chapter 
upon  "  Rural  Hygiene.") 

Salt  marshes. —  This  may  seem  a  strange  heading  under  parks.  But 
persons  who  have  been  about  the  Jersey  resorts  know  what  a  factor  of  dis- 
comfort the  peculiar  mosquito  of  these  regions  may  become.  While  the  pro- 
fession is  well  informed  concerning  the  species  of  mosquitoes  disseminating 
malarial  and  yellow  fevers,  they  are  not  so  well  instructed  concerning  the 
salt  water  mosquito. 

Dr.  A.  H.  Doty,  health  officer,  port  of  New  York,  and  located  at  Staten 
Island,  has  done  much  original  work  upon  the  life  history  and  the  methods 
of  successful  destruction  of  the  salt  water  mosquito.  I  went  to  see  the  doctor 
and  the  ditches  upon  the  island  and  found  that  he  has  succeeded  in  practically 
exterminating  this  species  of  insect  from  the  drained  region.  By  the  courtesy 
of  Dr.  Doty,  the  following  extracts  are  reproduced  from  reprints  with  which 
he  furnished  me,  derived  from  Reports  of  the  American  Public  Health  Asso- 
ciation and  the  American  Journal  of  the  Medical  Sciences. 

To  obtain  success  in  our  efforts  to  exterminate  the  mosquito  we  must  be  familiar 
with  the  manner  in  which  it  is  propagated,  its  habits,  etc.  First,  we  must  understand 
that  all  varieties  of  the  mosquito  propagate  only  in  water.  The  importance  of  this  lies 
in  the  fact  that  it  gives  us  definite  information  regarding  the  character  of  their  breeding 
places.  Thus  far  investigation  has  shown  that  all  mosquitoes,  with  the  exception  of 
the  sollicitans,  deposit  their  eggs  on  the  surface  of  the  water.  These  develop  into 
larvae,  commonly  known  as  "wigglers,"  and  then  into  pupae,  which  are  subsequently 
transformed  into  the  winged  insects.  From  the  deposit  of  the  eggs  to  the  development 
of  the  winged  insect  only  twelve  to  twenty-five  days  elapse,  depending  on  the  variety 
of  mosquito.  The  longest  period  is,  as  a  rule,  required  for  the  development  of  the 
anopheles  or  malarial  mosquito.  Until  recently  it  has  been  the  general  belief  that 
mosquitoes  deposit  their  eggs  only  upon  the  surface  of  the  water.  The  investigation 
of  Dr.  John  B.  Smith,  State  Entomologist  of  New  Jersey,  and  the  investigation  under 
my  direction  have  satisfactorily  demonstrated  the  fact  that  the  sollicitans,  when  free 
to  act,  deposit  its  eggs  on  the  ground  in  the  salt  marshes  along  the  coast,  although  in 
captivity  this  mosquito  may  deposit  its  eggs  on  water,  glass,  cotton,  or  on  almost  any- 
thing with  which  it  comes  in  contact.  However,  even  in  captivity,  it  will  be  found 
that,  if  earth  from  salt  marshes  be  placed  in  cages  containing  the  sollicitans,  it  will 
preferably  deposit  its  eggs  on  this  material ;  however,  the  development  of  the  eggs  does 
not  take  place  until  the  earth  is  covered  with  water.  In  the  salt  marshes  this  is  supplied 
by  the  frequent  floodings,  which  form  both  small  and  large  collections  of  water; 
many  of  these  remain  sufficiently  long  for  the  development  of  the  winged  insect. 
Therefore,  while  the  eggs  of  the  sollicitans  are  deposited  on  the  earth  in  salt  marshes, 
their  development  into  the  winged  insects  depends  upon  the  presence  of  water  in  the 
same  manner  required  by  other  varieties  of  the  mosquito. 


104  HYGIENE 

Culex  sollicttans. —  The  belief  thac  no  mosquito  will  breed  in  salt  water  is  erron- 
eous, inasmuch  as  the  culex  sollicttans  will  breed  in  no  other  place.  Therefore,  while 
we  suffer  the  annoyance  which  the  bite  of  the  sollicitans  inflicts,  i^  may  be  of  some  com- 
fort to  know  that  they  will  not  breed  inland  or  away  from  salt  marshes.  The  statement 
just  made  regarding  the  sollicitans  has  been  corroborated  by  careful  investigation  and 
experimental  work  which  I  have  conducted  during  the  past  five  years.  During  this 
period  specimens  of  water  containing  larvse  taken  from  all  kinds  of  receptacles  about 
dwelling  houses,  ground  depressions,  etc.,  either  in  close  proximity  or  some  distance 
removed  from  salt-water  swamps,  were  placed  in  large  glass  receptacles,  covered  with 
netting,  and  allowed  to  remain  until  the  winged  insects  were  developed,  but  in  no  in- 
stance did  the  sollicttans  develop  from  these  larvae.  A  number  of  times  larvae  have 
been  taken  from  inland  drains,  the  immediate  vicinity  of  which  was  thickly  infested 
with  the  sollicttans,  but  the  larvae  always  developed  into  the  culex  pungens,  or  "  in- 
land "  mosquito,  and  no  sollicttans  were  ever  found.  The  result  of  these  observa- 
tions gradually  directed  attention  to  the  salt  marshes  along  the  coast  as  the  seat  of 
propagation  of  the  sollicttans.  Here  in  the  pockets,  or  ground  depressions  containing 
salt  water,  the  larvae  of  this  variety  were  found  in  enormous  numbers;  this  was  proven 
by  placing  the  water  containing  larvae  in  large  glass  jars  covered  with  netting.  When 
the  winged  insects  appeared  they  were  in  every  instance  found  to  be  the  sollicitans,  and 
no  other  variety.  A  series  of  experiments  which  followed  consisted  in  the  transfer  of 
earth  from  these  swamps  to  the  laboratory,  where  k  was  placed  in  large  glass  jars 
covered  with  netting.  In  these  were  confined  the  sollicitans.  Soon  after  their  cap- 
tivity eggs  were  found  deposited  on  the  earth.  After  the  release  of  the  mosquitoes  the 
earth  upon  which  the  eggs  had  been  deposited  was  kept  intact  and  allowed  to  remain 
for  various  periods,  in  some  instances  for  four  months.  In  some  of  the  tests  the  earth 
was  kept  moist;  in  others  it  was  allowed  to  dry,  but  in  no  instance  was  there  any  fur- 
ther development  of  the  eggs  until  the  earth  was  covered  with  water;  then,  within 
twelve  hours  afterward,  the  larvae  appeared.  Other  experiments  consisted  in  placing 
earth  from  salt  water  warshes  in  wire  cages  also  containing  water  in  glass  jars.  The 
sollicttans  in  the  cages  preferably  deposited  their  eggs  on  the  earth  rather  than  on  the 
water.  The  results  to  which  I  have  referred  are  in  harmony  with  those  obtained  by 
Dr.  John  B.  Smith,  to  whom  credit  is  due  for  exceedingly  valuable  work  in  connection 
with  this  variety  of  mosquito. 

As  a  result  of  these  investigations  it  is  reasonable  to  assume  that  the  culex  solli- 
cttans breeds  only  in  salt-water  swamps,  and  that  their  eggs  are  deposited  upon  the 
earth  and  remain  without  further  change  until  covered  with  water,  when  the  develop- 
ment of  the  winged  insect  rapidly  follows.  It  is  also  reasonable  to  assume  that  the 
first  crop  of  the  sollicitans,  which  appears  in  the  spring  or  early  summer,  is  due  to  the 
hibernation  of  the  eggs  of  this  insect,  which  are  deposited  on  the  ground  late  in  the 
fall,  but  do  not  develop  until  the  warm  weather  of  the  following  year  appears,  and  the 
swamps  are  more  or  less  covered  with  water. 

On  the  other  hand,  it  is  equally  certain  that  the  culex  pungens,  or  "  inland  "  mos- 
quito, is  perpetuated  by  the  hibernation  of  the  winged  insect  itself,  and  not  by  its  eggs. 
It  is  a  frequent  occurrence  in  sections  where  this  variety  of  the  mosquito  breeds  to  find 
a  few  of  them  about  the  house  during  the  winter  months.  When  the  warm  weather 
appears  the  survivors  become  active  and  deposit  their  eggs  in  receptacles  containing 
water.  It  is  not  impossible  that  a  few  larvae  of  this  variety  may  hibernate  during  the 
winter,  as  in  some  instances  they  have  been  detected  in  ice,  warmed,  and  brought  to 
life.  However,  I  have  never  known  of  one  which  survived  more  than  a  short  time,  and 
I  am  quite  certain  that  they  do  not  play  an  important  part  in  perpetuating  their  species. 
The  statement  which  I  have  just  made  relative  to  the  perpetuation  of  the  culex  pungens 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  105 

may,  I  believe,  be  also  applied  to  the  anopheles  and  stegomyias,  although  regarding  the 
latter  variety  I  do  not  speak  from  personal  experience. 

There  is  good  reason  to  believe  that  the  stegomyia,  or  yellow-fever  mosquito,  like 
the  culex  pungens,  prefers  to  breed  in  contaminated  water. 

Extermination  of  the  Mosquito 

Careful  investigation  of  the  mosquito  has  shown  that  the  various  types  of  this 
insect  differ  in  their  method  of  propagation,  habits,  etc.  It  is  very  necessary  that  we 
should  be  familiar  with  this  fact,  inasmuch  as  the  means  by  which  the  mosquito  may  be 
exterminated  depend  largely  upon  the  variety  with  which  we  have  to  deal. 

The  importance  of  our  present  knowledge  regarding  the  culex  sollicitans  will  be 
better  appreciated  by  those  who  live  along  the  Altantic  coast,  and  who  are  constantly 
subjected  to  the  annoyance  of  this  variety  of  the  mosquito  during  the  warm  weather. 
It  is  a  well-known  fact  that  the  enormous  number  oi  sollicitans  present  has  seriously 
interfered  with  the  development  of  certain  sections  along  the  Atlantic  coast.  Before 
its  breeding  place  was  definitely  known  efforts  to  prevent  its  propagation  were  confined 
to  the  same  means  which  are  used  to  exterminate  the  culex  pungens,  anopheles,  and 
stegomyia,  such  as  the  care  of  inland  ground  depressions,  cisterns,  rain-water  barrels, 
and  other  receptacles.  We  now  know  that  such  methods  as  these  are  practically  use- 
less in  the  extermination  of  the  sollicitans,  and  it  is  only  by  the  proper  drainage  of  salt- 
water swamp  lands  along  the  coast  that  the  propagation  ofthis  variety  can  be  prevented. 
The  use  of  oil  in  the  extermination  of  this  variety  of  mosquito  even  as  a  temporary 
measure  is  but  of  little  or  no  value.  Although  the  sollicitans  deposits  its  eggs  on  the 
ground  in  the  swamps,  they  cannot  develop  without  water,  and,  if  accumulations  of 
surface  water  be  prevented  by  drainage,  propagation  ceases.  This  has  already  been 
successfully  demonstrated  in  some  of  the  New  Jersey  salt-water  swamps,  which  were 
impassable  and  thickly  infested  with  mosquitoes.  These  have  recently  been  ditched 
and  drained,  and  this  year  are  producing  crops  of  hay,  which  are  harvested  with 
mowing  machines.  Furthermore,  the  mosquito  has  practically  disappeared  in  the 
sections  thus  treated.  Work  of  a  similar  character  is  now  in  progress  along  the  Staten 
Island  coast,  and  it  is  confidently  expected  that  next  year  will  prove  the  success  of  this 
work. 

For  a  full  description  of  the  methods  of  ditching,  etc.,  used  by  Dr.  Doty, 
see  his  paper  in  the  May,  1908,  issue  of  the  New  York  State  Journal  of  Medi- 
cine. This  same  subject  is  referred  to  in  what  is  said  concerning  docks  and 
harbors,  in  Chapter  XXIII. 

What  is  said  above  is  a  matter  of  vital  interest  to  the  seaside  dweller  and 
to  municipalities  maintaining  parks  along  the  shore.  From  what  I  saw  at 
Staten  Island,  it  impresses  me  that  the  reclaimed  land  from  the  salt  marshes 
would  be  of  a  value  almost  if  not  quite  repaying  the  cost  of  ditching  and 
drainage.  Even  lands  failing  to  mature  the  ordinary  crops  will  readily  grow 
profitable  crops  of  the  salt  hay  used  for  packing  purposes.  As  to  salt  water 
mosquitoes,  it  is  asserted  that  in  the  Philippines  one  variety  of  them  do  carry 
malaria. 

Closing  natural  waterways. —  This  subject  is  suggested  by  the  preceding 
one.  State  boards  of  health  have  been  given  this  right  when  the  sanitary 
necessities  of  the  case  demanded  such  measures.  But  to  close  a  navigable 
waterway  is  another  matter.     However,  in  the  celebrated  Blackbird  Creek 


106  HYGIENE 

case,  of  Delaware,  the  supreme  court  upheld  the  right  of  a  state  to  close  a 
creek  for  sanitary  reasons.  There  can  be  no  question  but  that  insanitary  es- 
tuaries and  creeks  can  be  closed.  If,  however,  the  waterway  drains  a  large 
area  of  storm  water,  it  may  not  be  practicable  to  close  it  up  and  the  question 
arises  as  to  the  engineering  possibility  of  installing  a  large  drain  in  the  place  of 
the  stream.  This  cannot  be  answered  oflFhand.  Every  case  must  be  judged 
upon  its  own  merits,  but  a  few  things  must  not  be  forgotten.  It  is  very  easy 
for  an  engineer  to  base  his  plans  or  estimates  upon  an  average  flow.  This  is 
not  safe,  even  if  it  is  cheap.  Another  point  is  that  a  closed  sewer  needs  a 
greater  gradient  than  does  an  open  stream,  since  the  latter  has  an  initial 
velocity  and  the  suction  action  of  the  fall  below,  whereas  a  sewer  has  little 
chance  for  an  initial  velocity  and  often  discharges  against  resistance.  Conse- 
quently, the  sewer  is  apt  to  silt  up.  Park  boards  will  be  apt  to  involve  them- 
selves in  needless  expense  by  attempting  to  close  natural  waterways  or  turn 
open  drains  into  closed  ones.  The  thing  to  do  is  to  prevent  contamination 
and  then  the  open  drain  may  not  be  objectionable. 

Jrttficial  lakes  and  ponds. —  This  usually  involves  a  dam  so  constructed 
as  to  detain  the  flow  of  a  small  stream.  Several  factors  must  be  considered. 
First,  the  engineering  features  must  be  made  safe.  A  dam  is  always  a  poten- 
tial source  of  danger  and  every  foot  added  to  the  height  increases  that  danger. 
The  possible  engineering  features  are  so  many  that  I  will  touch  upon  but  a  few. 
It  is  always  wise  to  estimate  the  safe  sanitary  size  or  area  of  the  lake  upon  the 
minimum  flow.  Great  Salt  Lake  and  the  Dead  Sea  are  instances  of  bodies 
of  water  receiving  some  considerable  amount  of  water,  but  discharging  none. 
In  other  words,  evaporation  and  seepage  disposes  of  the  whole  available 
supply.  Fortunately,  they  are  filled  with  salt  and  do  not  become  ofi^ensive. 
Not  so  with  some  artificial  lakes  I  know.  A  photograph  of  a  lake  filled  up 
with  weeds  is  given  elsewhere,  and  it  will  also  serve  to  illustrate  this  subject. 
The  dam  construction  of  the  lake  is  excellent  and  the  general  engineering 
features  good,  but  the  several  persons  who  laid  it  out  probably  did  not  know 
the  minimum  flow  of  the  stream  supplying  it.  In  consequence,  the  area  of 
the  porous  bottom  and  the  surface  area  of  the  water  dispose  of  practically  the 
whole  supply  received  in  this  very  dry  summer,  and  when  I  took  the  photo- 
graph the  air  was  reeking  with  the  odor  of  dead  frogs.  Were  the  photo- 
graph taken  in  the  early  spring,  it  would  show  a  beautiful  stretch  of  water. 
Engineers  make  the  same  mistake  in  the  construction  of  power  dams  and  mil- 
lions of  dollars  are  tied  up  in  immense  concrete  dams  that  will  never  yield  divi- 
dends, because  the  minimum  flow  of  the  stream  measures  the  safe  maximum 
load  the  dynamos  may  be  expected  to  carry  when  the  company  is  under  con- 
tracts that  run  by  the  year.  That  is  bad  enough,  but  to  endanger  the  health 
of  a  city  is  even  worse.  Engineers  are  about  as  liable  to  make  mistakes  as  are 
physicians,  and  they  differ  among  each  other  nearly  as  much  when  it  comes  to 
debatable  questions.  Never  employ  a  cock-sure  park  engineer.  He  will  dilate 
upon  "the  certitude  of  any  profession  based  upon  mathematics,  the  only  exact 
science."  So  far  as  that  goes,  so  is  vital  statistics  based  upon  mathematics. 
I  understood  that  the  city  where  this  lake  is  located  sent  for  a  celebrated 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  107 

landscape  gardener  from  New  England.  He  advised  pulling  up  the  weeds 
and  raising  the  height  of  the  dam,  but  pond  weeds  in  the  North  and  ever  so 
much  further  South  are  two  sorts  of  propositions.  I  have  seen  pond  weeds 
in  the  South  that  a  mule  could  not  pull  and  pond  lilies  up  North  that  the 
current  is  apt  to  uproot. 

The  right  way  to  improve  that  lake  is  to  dredge  out  the  central  third  of 
it  to  a  minimum  of  six  feet  depth  and  deposit  the  earth  v\^here  its  shallow  sides 
are  now  filled  with  water  plants.  These  lakes  in  parks  are  a  great  source  of 
trouble  and  many  are  insanitary.  The  whole  idea  seems  to  be  to  beautify 
the  park,  and  the  two  mistakes  are  made  of  attempting  too  great  an  area  and 
making  the  lake  shallow,  so  that  it  is  safe  for  children.  The  latter  plan 
almost  invariably  results  in  the  lake  filling  up  with  water  vegetation.  If  the 
excavation  is  well  treated  with  crude  coal  oil  before  the  water  is  let  in,  the 
weeds  are  killed  for  the  time  at  least.  Once  they  are  established,  pulling 
them  up  does  little  appreciable  good.  Some  places  use  a  sort  of  drag  saw  to 
cut  the  vegetation,  but  it  grows  right  up  again.  All  such  lakes  should  be 
well  stocked  with  mosquito-eating  fish.  Parking  waste  lands  and  swamps 
costs  money  out  of  all  proportion  to  the  results,  but  if  sanitation  is  conserved 
and  the  city  gets  the  land  for  nothing,  it  may  be  worth  the  outlay.  Other 
things  being  equal,  it  is  better  to  pay  for  good  park  land  that  is  capable  of 
development  with  a  reasonable  outlay.  Swamps  are  a  dismal  proposition 
to  undertake  in  any  line  of  development.  City  water  fronts  are  a  neglected 
possibility  in  the  way  of  parkways.  Harrisburg  is  developing  a  very  beautiful 
water  front  parkway,  nearly  two  miles  in  length.  The  sanitary  advantages 
of  the  city  controlling  the  water  front  are  manifold.  i3 

Municipal  parks. —  From  the  side  of  sanitation  there  is  but  little  to  say. 
All  over  this  country  parks  are  being  elaborated  and  a  large  number  of  very 
well-informed  park  boards  exist,  whose  experience  justifies  the  large  amount 
of  literature  emanating  from  them  principally  as  individuals.  The  present 
writer  has  made  a  partial  survey  of  this  literature  and  finds  the  subject  so 
large  that  we  can  but  suggest  that  interested  persons  should  not  depend  upon 
a  work  upon  public  hygiene  for  general  information  about  parks. 

However,  the  writer  must  be  pardoned  if  he  suggests  that  some  of  this 
literature  is  stilted  and  theoretical.  There  are  one-sided  persons  in  every 
department  of  literature.  It  is  well  for  us  never  to  forget  that  public  parks 
are  for  the  public;  that  driveways  far  from  the  city  but  built  at  city  expense 
do  not  supply  the  legitimate  place  of  a  public  park,  since  only  the  small  por- 
tion of  the  public  owning  horses  and  carriages  and  automobiles  get  to  even 
see  them;  that  "  keep  off  the  grass  "  signs  can  be  very  much  overdone  and 
are  but  little  seen  in  the  really  model  parks  of  the  land;  that  as  trolley  cars  are 
the  vehicle  of  the  great  mass  of  people,  it  is  folly  to  exclude  them  from  parks 
at  a  distance  from  the  city  or  to  exclude  cars  from  adjoining  places  while 
such  an  important  park  as  Fairmount  Park  in  Philadelphia  has  a  trolley 
line  built  to  its  more  interesting  portions;  that  the  pretty  plans  upon  paper 
are  not  matters  of  "  plenary  inspiration  "  and  usually  need  considerable 
toning  down;  that  the  maintenance  of  a  park  is  expensiveand  is  just  as  im- 
portant as  is  its  original  laying  out;  that  policing  of  parks  is  imperative;  that  a 


108  HYGIENE 

plant  that  works  well  in  a  certain  latitude  and  with  a  certain  kind  of  soil  may 
fail  dismally  under  other  circumstances;  that  even  park  boards  cannot 
change  the  natural  habitat  of  plants  and  trees,  and  that  the  old-fashioned 
gardener  of  the  neighborhood  may  be  in  position  to  give  more  true  expert 
advice  than  can  the  expensive  expert  from  a  distance;  and  that  the  politician 
seldom  knows  much  about  any  trees  except  the  "  plum  tree." 

From  the  sanitary  point  of  view,  what  has  been  said  under  other  headings 
applies  here,  but  there  is  an  especial  danger  in  parks  that  the  local  boards  of 
health  should  regulate,  and  that  is  that  children  recovering  from  long  illnesses 
and  sometimes  from  infectious  diseases  are  frequently  taken  to  parks  and 
come  into  contact  with  healthy  children.  Tuberculous  cases  should  also  be 
watched  that  they  do  not  expectorate  upon  park  property. 

Parking  of  public  grounds. — A  photograph  herein  shows  hov/  a  formerly 
unsightly  waterworks  grounds  may  be  made  a  thing  of  beauty  and  of  health, 
it  is  but  one  instance  of  many  that  I  might  give  showing  how  the  factories 
and  public  buildings  of  the  country  are  being  made  centers  of  fine  parks 
that  are  object  lessons  to  the  community  and  that  indirectly  influence  the 
people  to  better  things  in  beauty  and  in  hygiene.  However,  the  matter  can 
be  overdone.  School  grounds  have  been  parked  in  many  places  to  such  an 
extent  that  the  children  had  no  place  for  their  sports  and  games.  It  is  vastly 
more  important  that  a  base  ball  diamond  be  laid  out  for  the  boys  than  that  the 
flower  beds  be  used  to  teach  botany.  Nearly  all  city  schools  have  too  con- 
tracted grounds,  and  it  would  be  well  to  use  some  of  the  park  funds  to  pur- 
chase property  contiguous  to  the  school  buildings  and  tear  them  down  to 
give  space  to  the  children  and  their  games.  School  grounds  should  be  kept 
open,  under  proper  supervision,  for  the  use  of  the  children  during  the  summer 
vacations.  Public  playgrounds  are  a  good  investment,  but  they  should  be 
playgrounds  rather  than  places  to  exploit  the  ideas  of  the  apostles  of  beauty 
and  various  phases  of  alleged  teaching.  We  illustrate  one  in  Harrisburg  that 
is  placed  upon  an  island  surrounded  with  shallow  water.  The  park  board 
employs  a  physical  culture  professor  there  and  allows  all  this  part  of  the  state 
to  have  their  sports  there.  The  intercollegiate  track  meet  and  high  school 
athletics  and  all  the  contests  upon  land  and  water  that  so  delight  the  hearts 
of  young  America  keep  enthusiasm  and  noise  there  at  high  pressure.  It  costs 
very  little  to  keep  it  up  compared  to  the  good  it  does,  and  there  is  not  a  flower- 
bed upon  the  place.  There  are  tennis  courts,  bathing  facilities,  a  fine  run- 
ning track,  and  everything  needed  in  the  way  of  athletic  appliances,  and  the 
only  disadvantage  is  two  cents'  bridge  toll  for  the  otherwise  free  use  of  the 
island.  Another  playground  is  adapted  to  smaller  children  and  has  swings,  a 
shallow  wading  pond,  arrangements  for  games,  etc. 

Railroad  parking  is  to  be  commended.  Some  roads  spend  considerable 
sums  in  beautifying  their  various  grounds  and  sodding  theii  embankments. 
Some  of  the  most  intelUgent  park  work  I  have  seen  is  done  by  railroad 
companies. 

Amusement  parks. —  Were  we  to  have  written  this  a  few  years  ago,  there 
would  have  been  much  to  say  in  condemnation.  As  it  is,  the  writer  is  just 
back  from  seeing  Coney  Island,  Luna  Park  at  Washington,  Electric  Park  at 


THE    YOUNG    ATHLETE  S    PARADISE 

WHERE    THE    UNFORTUNATE    IN    NEW    YORK    SO    OFTEN    SLEEP 

bears'    den,    zoological    GARDEN,    PHILADELPHIA 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  109 

Baltimore,  and  other  presumably  rather  dizzy  resorts.  While  a  clergyman 
would  see  much  oi"  Sabbath  desecration,  and  which  lam  inclined  to  condemn 
as  well,  and  the  student  of  ethnology  could  see  many  problems  suggested  by 
the  crowds,  there  is  little  of  gross  violation  of  sanitation  to  be  found  in  these 
places.  Smaller  places,  where  local  boards  of  health  have  gone  to  sleep,  are 
just  as  bad  as  ever.  It  is  a  matter  purely  in  the  hands  ct  the  sanitary  authori- 
ties and  we  could  tell  some  of  them  about  places  of  which  they  should  know 
themselves.  Out  in  one  of  the  great  lakes  there  used  to  be  an  island  resort 
rightly  described  as  "  a  little  hell."  It  was  closed  long  ago.  The  editor  tried  to 
find  the  worst  parts  of  it  and  failed  dismally  in  locating  anything  that  he  could 
really  say  was  bad  from  any  point  of  view.  The  trouble  was  he  was  not 
known,  and  was  spotted  because  he  was  in  conversation  with  a  policeman 
who  located  him  as  a  "  squealer."  But  if  the  reader  thinks  that  sort  of  pro- 
tected vice  is  out  of  style  everywhere  he  is  sadly  mistaken.  From  an  ad- 
mittedly superficial  observation  of  such  places  we  can  suggest  no  real  remedy 
except  the  general  diffusion  of  religious  and  moral  teaching  and  the  enforce- 
ment of  law.  As  it  impresses  me,  no  man  with  the  instincts  of  a  gentleman 
can  be  anything  but  disgusted  at  such  places.  If  he  has  not  such  instincts, 
he  will  usually  find  some  way  to  gratify  the  base  and  animal  instincts  that 
usurp  the  place  of  the  manhood  he  has  lost.  Such  resorts  as  cater  to  such 
people  are  usually  controlled  by  that  coterie  that  are  the  hybrid  children  of 
debased  politics  upon  one  side  and  the  worst  saloon  element  upon  the  other. 
Not  that  all  politics  is  bad  or  that  all  saloons  are  vile,  for  that  would  be  an 
unwarranted  generalization,  but  the  combination  of  politics  and  liquor  is 
wholly  debased  and  its  institutions  the  worst  enemies  of  the  national  man- 
hood and  womanhood. 

The  editor  lived  in  Pittsburg  at  the  time  a  reform  mayor  tried  to  clean 
up  the  city  and  enforce  the  Sabbath  laws.  He  meant  well,  but  he  did  more 
harm  than  good.  Driving  certain  things  to  cover  does  not  abolish  them. 
Certain  cities  to-day  are  congratulating  themselves  that  they  have  suppressed 
vice.  Let  their  officials  visit  some  of  the  small  amusement  parks  and  beer 
gardens  outside  the  city  limits,  and  they  will  see  what  they  will  see.  If  they 
should  visit  a  place  we  know  of  they  would  be  apt  to  see  the  chief  of  police 
in  citizens'  clothing  and  accompanied  by  bad  characters  he  should  arrest 
for  known  violation  of  law.  We  do  not  drink  beer  or  anything  intoxicating, 
but  have  made  it  our  care  to  see  things  before  writing  about  them,  and  it  is  a 
shame  how  the  outskirts  of  some  of  our  cities  are  made  the  refuge  of  the  worst 
element  living  in  the  cities,  and  that  moral  and  sanitary  matters  are  neglected 
where  the  neglect  is  doing  most  harm.  In  some  places  boards  of  health  have 
jurisdiction  for  one  mile  beyond  the  corporate  limits.  Were  that  the  case 
everywhere  and  the  same  power  given  to  police,  much  could  be  done  to  rectify 
the  conditions  of  which  we  speak.  But  where  the  police  and  the  saloons  are 
manipulated  by  the  same  wires,  the  case  is  hopeless  unless  a  miracle  happens, 
the  city  voter  becoming  really  aroused. 

As  to  what  we  have  not  seen  at  Coney  Island  and  other  re- 
sorts, we  have  simply  to  say  that  careful  citizens  miss  seeing  a  host 
of  things  and  we  may    not    be     an    exception,    but    the    outward    moral 


no  HYGIENE 

conditions  of  parks  and  resorts  seem  to  keep  equal  pace  with  their 
sanitary  conditions. 

At  this  moment  an  automobile  chemical  engine  dashed  past  the  house. 
That  means  it  is  not  worth  while  to  see  where  the  fire  is  for  it  will  probably  be 
extinguished  within  five  minutes.  We  have  learned  to  suppress  physical 
fire  in  its  incipiency  and  the  devices  for  physical  safety  are  innumerable, 
but  the  same  old  moral  abuses  go  on  from  year  to  year  and  only  vary  in  their 
phases.  As  to  this  one,  park  boards  over  the  country  should  take  the  matter 
up  in  the  interest  of  decent  parks.  It  would  be  well  for  the  trolley  and  excur- 
sion boat  people  to  co-operate  and  the  boards  of  health  to  do  their  part  as  well. 

Expositions. —  In  closing  this  section  of  places  of  amusement,  we  beg 
to  reproduce  an  editorial  appearing  in  the  Medical  Council  a  couple  of  years 
ago. 

An  Exposition  Menace 

Quite  a  contention  has  arisen  between  Major  Charles  E.  Woodruff,  chief  surgeon  of 
the  United  Sta'  es  Army  camp  at  the  Jamestown  Exposition,  and  Dr.  R.  L.  Payne,  medi- 
cal director  of  the  exposition.  They  are  both  most  excellent  gentlemen,  one  taking  the 
rigid  army  sanitation  point  of  view  and  the  other  the  more  easy-going  attitude  of  the 
civilian.  From  a  non-biased  review  of  their  several  contentions,  in  the  Military  Surgeon 
of  December,  1907,  as  well  as  our  own  superficial  observation  of  other  expositions,  it 
has  forcibly  impressed  us  that  the  waterways  of  a  natural  and  artificial  order,  the  im- 
perfect drinking  water  and  sewage  systems,  the  filthy  camps  of  Indians  and  even  less 
civilized  peoples,  the  presence  of  numerous  animals,  the  flimsy  hotels  and  restaurants, 
the  moral  turpitude  of  the  "  outside  attractions,"  the  poor  quality  of  the  food,  lax 
management,  the  camps  of  laborers,  crowded  conveyances,  the  dust  and  the  com- 
mingling of  so  many  people  in  close  quarters  —  all  tend  toward  making  an  exposition 
a  mosL  unsanitary  place  to  visit. 

We  have  no  doubt  at  all  that  Major  Woodruff  is  correct  in  his  statements  that  to 
keep  his  camp  free  of  typhoid,  admittedly  present  in  many  places  in  the  vicinity,  was 
an  almost  herculean  task,  but  we  also  have  no  doubt  that  Dr.  Payne  and  gentlemen 
holding  similar  positions  in  previous  expositions  were  very  distinctly  "  up  against  "  a 
hard   task. 

Sanitary  regulations  are  more  readily  enforced  in  a  military  camp  than  in  the 
cosmopolitan  and  motley  crew  of  hunters  for  easy  money  holding  the  concessions  in 
and  about  the  great  exposition.  The  whole  matter  has  a  very  serious  and  threatening 
aspect  to  the  trained  sanitarian.  The  average  physician  who  has  not  been  brought 
into  frequent  contact  with  army  camps  has  really  li-tle  conception  of  the  dangers  ever 
lurking  there,  and  of  the  elaborate  precautions  taken  to  prevent  illness.  No  exposition 
can,  in  the  nature  of  the  case,  be  made  as  safe  as  is  an  army  camp. 

Now  that  so  much  money  has  been  lost  in  great  expositions,  we  hope  they  will  be 
abandoned  in  future  or  limited  in  scope  and  camp  features.  The  people  of  Norfolk  are 
entitled  to  more  praise  than  was  given  them  by  the  newspapers.  It  is  a  thriving  city, 
containing  hosts  of  en.-erprising  and  cultured  citizens,  who  sacrificed  much  upon  an 
exposition  having  many  admirable  features,  but  the  defects  inherent  in  all  such  under- 
takings were  accentuated  in  a  semi-tropical  region. 

We  are  much  inclined  to  fear  that  the  civilian  physician  has  many  lessons  to  leam 
from  the  modern  army  sanitarian,  and  we  believe  any  future  exposition  should  have 
army  officers  or  men  of  army  training  in  charge  of  its  sanitation. 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  111 

The  Sanitation  of  Seaside  Resorts* 

The  sanitar}'  problems  of  seaside  resorts  are  materially  influenced  by 
the  great  fluctuation  of  permanent  and  transient  population  at  different 
seasons  of  the  year.  When  one  considers  an  increase  of  from  one  hundred 
to  five  hundred  per  cent  in  summer,  and  with  people  coming  from  all  parts  of 
the  world,  a  proper  sanitary  administration  of  public  affairs  presents  some 
unique  questions.  The  permanent  population  living  in  cottages  and  flats  is 
treated  the  same  as  in  any  town  or  city;  but  the  great  summer  rush  into 
hotels,  boarding  houses,  and  cottages  necessarily  brings  with  it  sanitary 
dangers  that  demand  radical  handling. 

Boards  of  health. —  To  rigidly  enforce  sanitary  laws  an  efficient  board  of 
health  entirely  divorced  from  politics  is  an  absolute  necessity.  It  should 
comprise  in  its  membership  representatives  of  the  medical  profession  and 
of  the  hotel  and  business  interests,  all  being  good  representative  property 
owners,  whose  main  aim  shall  be  to  protect  visitors  as  well  as  home  popu- 
lation. When  one  considers  a  single  hotel  accommodating  at  one  time  a 
village  of  twelve  hundred  people,  it  is  necessary  to  have  most  rigid  sanitation 
and  thorough  systematic  inspection  at  frequent  intervals.  In  fact,  the  man- 
agement of  the  house  should  establish  his  own  sanitary  corps  upon  such  a 
thorough  basis  that  no  routine  problems  in  his  place  should  demand  outside 
interference.  Every  successful  seaside  hotel  adopts  this  principle,  and  many 
penalize  their  help  for  any  neglect  of  sanitary  law.  The  problem  of  handling 
contagious  and  infectious  diseases  in  these  seashore  hotels  demands  the 
utmost  secrecy,  as  the  outbreak  of  one  case,  publicly  announced  to  the  guests, 
usually  causes  a  panic  and  exodus  that  is  financially  detrimental  to  the  hotel 
interests  and  also  makes  possible  a  general  spread  of  diseases.  It  is  decidedly 
impolitic  to  quarantine  a  whole  hotel  in  midseason,  unless  the  exposure  has 
been  so  flagrant  and  general  as  to  absolutely  demand  it.  Immediate,  early 
reports  of  every  case  of  illness  to  the  management  must  be  demanded,  and 
every  case  of  real  or  suspected  contagion  should  be  removed  at  once  to  the 
municipal  hospital  (if  there  is  one  in  the  resort),  or,  if  not,  then  to  a  proper 
house  of  detention  and  treatment.  A  thorough,  systematic  fumigation,  reno- 
vation, and  cleaning  must  always  follow  before  the  rooms  are  thrown  open  to 
other  guests.  Every  seaside  hotel  should  demand  vaccination  or  a  certificate 
of  recent  successful  vaccination  from  ever}  employee.  This  is  mandatory 
of  employees  in  every  large  hotel  in  Atlantic  City.  Unless  complied  with  no 
one  can  remain  upon  or  be  added  to  the  hotel  staff.  Years  of  trial  in  Atlantic 
City  have  shown  this  method  of  quarantine  and  reports  to  be  absolutely  safe, 
and  where  properly  enforced  none  will  suffer.  It  is  also  unwise  to  placard 
houses  in  seaside  resorts  for  contagion,  as  the  moral  effect  upon  transient 
population  is  bad  and  tends  to  drive  thousands  home  without  cause. 

The  panicky  condition  of  the  public  at  large  is  well  illustrated  by  out- 
breaks of  variola,  yellow  fever,  and  other  contagious  diseases,  when  they 
migrate  by  the  thousands  to  our  seaside  and  other  resorts.     At  these  times 

*By  W.  Blair  Stewart,  A.M.,  M.D. 


112  HYGIENE 

too  great  sanitary  restrictions  cannot  be  administered,  and  every  hotel  pro- 
prietor should  be  especially  cautioned  to  watch  closely  for  and  immediately 
report  every  suspicious  case.  Here,  as  in  all  towns  and  cities,  the  board  of 
health  should  insist  upon  thorough  quarantine,  and  it  can  be  accomplished 
in  resorts,  as  well  without  as  with  the  usual  placard.  Variola  should  always 
be  removed  to  the  municipal  hospital  or  held  under  special  officer  quarantine. 
Systematic  renovation  and  fumigation  should  be  demanded  of  every  hotel 
at  the  close  of  or  before  the  opening  of  a  new  season. 

The  problems  of  food  supply  differ  little  from  the  interior,  except  that  the 
clam  and  oyster  supply  needs  the  greatest  regulation.  Residents  and  dealers 
too  often  dredge  their  supply  from  the  sewage -infected  waters,  or,  what  is  of 
equal  importance,  fatten  their  oysters  on  half  fresh  water  and  half  sewage- 
infected  sea  water  mixed  together.  Where  the  waters  are  infected  too  rigid  laws 
cannot  be  enforced  in  regard  to  this  question.  The  board  of  health  of  Atlantic 
City  does  not  allow  the  delivery,  sale,  or  use  of  oysters  or  clams  taken  from  or 
fattened  in  the  waters  within  five  miles  of  the  resort.  As  a  still  further  pre- 
caution the  leading  hotels  do  not  serve  oysters  in  any  form  on  their  regular 
menu  during  July  and  August. 

Sewerage. —  Most  seaside  resorts  pump  their  sewage  without  sedimenta- 
tion directl}-  into  the  ocean  or  the  large  tide-water  thoroughfares,  acting  upon 
the  principle  that  the  dilution  is  so  great  and  the  antiseptic  qualities  of  sea 
water  so  decided  that  no  harm  results.  While  this  may  be  true  to  a  limited 
degree,  the  time  will  come  when  it  will  prove  a  decided  unsanitary  measure. 
Evidences  of  this  are  noticeable  in  some  resorts  where,  during  certain  tides, 
considerable  excrement  and  foreign  materials  wash  upon  the  beach.  Some 
system  of  sedimentation  or  purification  should  be  adopted  by  every  resort  to 
provide  against  future  trouble.  Open  filter  beds  in  Atlantic  City  proved  to 
be  so  much  of  a  nuisance  that  they  were  abandoned  years  ago.  The  handling 
of  seaside  sewage  resolves  itself  into  a  pumping  system,  such  as  must  be 
adopted  in  any  flat  country.  The  strain  here  is  the  pumping  a  reduced  quan- 
tity in  winter  and  a  vastly  increased  amount  in  summer  and  yet  so  arrange 
things  that  local  insanitary  conditions  do  not  arise.  This  is  successfully  done. 
Garbage. —  The  sj^stem  of  towing  garbage  miles  to  sea  in  scows  is  to  be 
discouraged.  Cooking  of  garbage  is  also  a  nuisance,  as  it  will  not  be  done 
without  unpleasant  odors.  Incineration  seems  to  be  most  satisfactory  here. 
Many  hotels  can  burn  their  own  garbage  in  special  range  racks  to  great 
advantage  as  to  heat-saving  and  eliminating  the  visits  of  the  too  often  insani- 
tary garbage  carts.  (See  Chapter  II  in  regard  to  hotel  sanitation  in  general; 
Chapter  XXII  upon  the  sewage  and  garbage  questions  and  the  chapters  upon 
quarantine  and  boards  of  health.) 

Mosquitoes  and  Flies. —  The  mosquito  is  best  banished  from  the  seaside 
resorts  by  filling  all  lowlands,  draining  all  meadows  and  destro)ing  every 
breeding  point  possible.  The  proper  and  persistent  crusade  against  filth 
and  open  manure  heaps  will  soon  abolish  the  fly  nuisance,  as  has  been  done 
by  many  resorts.  (Read  details  upon  the  salt  water  mosquito  under 
"  Parks,"  in  Chapter  VI.) 

Water  supply. —  Where  a  proper  artesian  supply  is  available,  large  hotels 


/COr 


SEWERAGE    PLANT,    ATLANTIC    CITY 

There  is  no  odor  resulting  from  the  process  here  used 


LOCKER    ROOM.       SANITARY    BATHHOUSE,    ATLANTIC    CITY 


PLACES  OF  AMUSEMENT  AND  DISSIPATION  113 

drive  their  own  wells,  fitted  with  absolutely  impervious  casings,  and  deliver 
for  use  to  their  guests  water  that  has  never  been  exposed  to  the  air,  light,  or 
any  possibility  of  outside  contamination.  In  fact,  many  shore  resorts  supply 
artesian  water  to  the  entire  community  during  the  greater  part  of  the  year  and 
a  mixed  artesian  and  stream  water  in  summer.  As  another  sanitary  measure, 
some  hotels  deliver  artesian  water,  from  their  own  system,  through  pipes 
coiled  through  a  refrigerating  chamber  and  connected  to  each  room,  thus 
giving  a  cold,  potable,  pure  water  instead  of  water  iced  with  a  dubious  source 
of  supply,  as  is  most  commonly  done. 

Bathing  establishments. —  With  from  one  to  five  thousand  people  bathing 
from  one  establishment  in  one  day,  the  same  suit  often  used  several  times,  and 
a  common  towel  supply,  we  have  a  great  source  of  possible  communication  of 
scabies,  favus,  syphilis,  gonorrhoea,  eye  troubles,  and  all  forms  of  communi- 
cable maladies.  These  places  should  come  under  strictest  supervision  and  a 
general  campaign  of  education  and  inspection  established.  The  modern 
up  to  date  bathing  establishment  must  be  sanitary  in  its  surroundings,  most 
scrupulously  cleaned,  ventilated,  and  drained.  Floors  should  be  of  tile  or 
smooth  concrete,  there  should  be  proper  rooms  for  dressing  and  toilet  pur- 
poses, and  a  system  of  thorough  steaming,  washing,  and  drying  to  supply 
perfectly  clean  suits  and  towels  for  each  person.  The  spirit  of  competition 
has  fortunately  supplied  these  necessities  in  spite  of  neglectful  boards  of 
health.  Many  of  these  bath  houses  refuse  service  to  those  known  to  have 
or  who  are  suspected  of  having  contagious  maladies.  Every  bathing  estab- 
lishment should  be  made  to  conform  to  the  strictest  sanitary  laws  and  should 
be  allowed  to  conduct  business  only  upon  a  permit  given  by  the  authority  of  a 
strict  board  of  health. 

Hospitals. —  The  day  of  treating  contagious  diseases  in  hotels  and  cot- 
tages is  practically  past,  and  every  seaside  resort  must  have  its  own  municipal 
hospital  conducted  upon  such  lines  as  will  conform  to  the  needs  of  the  poor  as 
well  as  those  of  the  most  fastidious.  A  hospital  for  the  treatment  of  general 
infectious  troubles  of  less  danger  is  a  necessity  as  well.  Added  to  such  pro- 
vision, Atlantic  City  has  established  a  fully  equipped  central  hospital  tent  and 
two  auxiliary  tents  upon  the  beach  front  bathing  grounds,  where  hundreds  of 
cases  are  given  first  aid  treatment  and  many  cases  of  communicable  disease 
are  first  recognized  and  recommended  for  proper  treatment.  Three  physi- 
cians of  proper  standing  are  in  charge  during  bathing  hours  in  the  regular 
season.  They  also  report  to  the  proper  authorities  all  unhygienic  conditions 
coming  under  their  notice  and  often  receive  complaints  of  insanitary  states 
needing  correction.  Every  seaside  resort  with  a  large  bathing  contingent 
can  well  copy  this  method  as  a  protection  and  sanitary  beach  front  necessity. 

Death  rate. —  The  seaside  resorts  are  the  most  healthy  in  the  world  as 
regards  permanent  population,  and  the  proper  death  rate  is  among  the  lowest. 
Records  of  state  boards  of  health  do  not  show  this  to  be  the  fact,  as  their  statis- 
tics are  based  upon  deaths  among  permanent  population  and  transients  as  a 
unit.  The  latter  outnumber  the  former  two  or  three  to  one,  since  thousands 
of  invalids,  convalescents,  and  incurables  are  sent  here  either  to  recover  or  to 
die,  and  a  due  proportion  accomplish  the  latter  outcome.     It  is  not  fair  to 


114  HYGIENE 

any  resort  to  take  the  death  rate  of  other  places  and  add  it  to  its  own  and 
publish  it  to  the  world  at  large  as  representing  the  true  conditions  present.  A 
fair  death  rate  cannot  be  computed  upon  a  basis  of  40,000  permanent  popula- 
tion when  the  deaths  occur  among  over  200,000  visitors  as  well. 


Chapter  VII 
SLUMS  AND  TOWN  NUISANCES* 

Building  laws  and  the  slums  —  What  we  should  and  may  expect  of  owners, 
tenants,  and  the  authorities  —  Inadequate  laws  in  many  places  —  Manure  and  factory 
refuse  — The  smoke  evil — Sewers — Stagnant  water  and  mosquitoes — Public  dumps — 
Garbage  disposal  —  Dirty  vacant  lots  —  Weeds  —  Offensive  manufacturing  and  mine 
refuse  —  Rats  and  bubonic  plague. 

THE  ideal  community  would  have  neither  slums  nor  nuisances,  and  in 
consequence  its  expense  for  the  adm.Inistration  of  justice,  for  charities, 
and  for  the  correction  of  social  disorders  veould  be  at  a  minimum. 
This  ideal  community  would  provide  the  highest  possible  personal  efficiency, 
and  I  take  it  that  such  is  the  effort  of  all  modern  philanthropic  and  sanitary 
work.  When  we  shall  have  realized  that  all  unnecessary  illness,  all  loss  of 
opportunity  for  gainful  work,  all  restraint  from  industry  by  judicial  or  other 
means,  and  the  cost  of  all  effort  to  relieve  distress,  make  up  a  sum  which 
bears  in  the  last  analysis  upon  every  member  of  the  community,  we  shall 
begin  to  see  that  the  slum  is  a  heavy  expense  to  the  better  portions  of  the  com- 
munity, and  that  nuisances  concern  everybody. 

Building  laws  and  the  slums. —  So  long  as  no  restraint  is  placed  upon  the 
cupidity  of  the  incidental  possessor  of  a  portion  of  the  earth's  surface,  on  the 
one  hand,  and  upon  the  foolishness  of  the  unfortunate  or  careless,  on  the 
other  hand,  slums  will  exist.  It  is  well  understood  that  a  definite  relation 
exists  between  healthful  conditions  and  the  number  of  cubic  feet  of  indoor 
space  allowed  for  each  individual  in  a  dwelling.  But  this  understanding 
does  not  always  assume  legal  shape  or  have  bearing  upon  the  builder  or  the 
owner  of  real  estate,  who  calculates  his  possible  income  regardless  of  the 
future  effect  on  humanity. 

One  of  the  first  things  needful  in  bringing  about  a  state  of  public  senti- 
ment which  will  produce  proper  building  laws,  and  then  enforce  them,  is  the 
understanding  that  a  man  who  so  uses  property  in  his  hands  as  to  damage  his 
neighbor  now  or  in  the  future  is  working  evil  and  wrong,  and  is  not  deserving 
of  public  respect.  Not  unfrequently  men  of  really  good  intent,  whose  lives 
are  beyond  reproach,  for  the  most  part,  are  among  the  most  inveterate  offend- 
ers in  respect  to  the  contraction  of  space  in  which  a  human  being  may  be 
expected  to  exist.  I  have  in  mind  a  Sunday  school  superintendent  who  has 
but  recently  erected  two  dwellings  and  a  store  on  a  piece  of  ground  of  eight 
feet  front  by  some  hundred  feet  in  depth.  Another,  occupying  an  important 
position  in  a  strong  church,  is  extending  his  operations  into  the  open  country 
in  such  fashion  as  to  prevent  any  possibility  of  sunlight  or  fresh  air  getting 
into  the  habitations  he  causes  to  be  erected.  Another  who  seeks  public  honor 
is  selling  habitations  built  upon  lots  14  by  85  feet  on  land  bought  by  the  acre. 

When,  as  I  have  above  suggested,  it  is  understood  that  such  men  as  these 
are  blood  guilty,  and  when  they  are  looked  down  upon  because  of  their  cupid- 

*By  J.  Horace  McFarland,  President  American  Civic  Association. 


116  HYGIENE 

ity,  selfishness,  and  disregard  to  the  public  health,  then  proper  laws  will  be 
possible  but  unnecessary.  Meanwhile,  it  is  important  that  any  thoughtful 
community  should  safeguard  itself  by  an  insistence  upon  the  enactment  of 
such  laws  as  shall  provide  against  the  evils  of  the  slum. 

It  should  not  be  understood  that  only  the  large  cities,  with  their  much 
talked  of  "  tenements,"  are  offenders  in  this  respect.  Many  of  the  smaller 
cities,  especially  in  eastern  Pennsylvania,  are  fully  as  wrong  in  this  respect  as 
are  the  larger  and  more  congested  cities;  indeed,  they  are  worse,  for  in  the 
larger  places  attention  has  been  called  and  there  are  building  regulations  and 
a  considerable  oversight  of  housing  conditions.  In  the  smaller  places,  on  the 
contrary,  the  tenement  is  simply  laid  on  its  side  in  the  shape  of  monotonous 
blocks,  with  conditions  which  rapidly  become  as  offensive  as  the  worst  high 
tenements  in  the  larger  cities. 

A  noted  writer  on  the  national  health  has  recently  observed  that  the 
shelter  of  our  houses  is  responsible  for  much  of  the  sickness  which  the  medical 
profession  combats.  He  has  urged  that  a  point  of  view  be  taken  under  which 
shelter  shall  be  incidental  and  the  outdoors  shall  be  brought  indoors  as  much 
as  possible.  Two  primary  points  may  therefore  be  set  down  as  necessary 
to  be  considered  in  respect  to  building  laws  in  the  efficient  community. 

The  first  is  that  a  certain  adequate  space  shall  be  provided  for  each 
individual,  and  the  number  of  individuals  permitted  to  live  in  any  structure 
erected  shall  be  proportioned  to  that  space.  The  second  is  that  such  buildings 
shall  be  so  arranged  with  respect  to  the  access  of  light  and  air  as  to  make  it 
possible  to  bring  the  outdoors  indoors. 

I  do  not  conceive  that  it  is  necessary  in  this  connection  for  me  to  give 
figures,  but  merely  that  it  is  important  to  suggest  the  underlying  principle, 
from  which  details  may  readily  be  worked  out. 

Another  of  the  ways  in  which  cupidity  and  carelessness  combine  to  create 
slums  where  there  should  be  only  healthy,  sightly,  and  pleasant  conditions,  is 
that  connected  with  building  in  blocks,  in  which,  as  a  matter  of  fact,  there  are 
but  four  walls  and  a  roof,  the  intervening  lath  and  plaster,  or  single  brick 
partitions,  being  merely  impervious  to  light,  and  not  to  sound,  odors,  or  con- 
versation. Obviously,  there  can  be  no  proper  family  life  amid  the  promis- 
cuous conditions  which  prevail  where  the  odors  of  cooking  go  from  end  to  end, 
in  the  accursed  dwellings  under  discussion,  where  the  least  noise  is  trans- 
mitted through  the  several  partitions,  and  where  sleep  is  made  troubled  or 
impossible  because  the  person  in  the  dwelling  making  the  latest  noise  at  night 
controls  the  situation,  in  connection  with  the  one  who  rises  earliest  in  the 
morning. 

The  model  building  law,  therefore,  should  not  only  provide  in  respect 
to  the  number  of  cubic  feet  allowed  for  each  individual,  and  in  respect  to  the 
admission  of  light  and  air,  but  should,  as  well,  provide  against  the  block,  w^ith 
its  flimsy  partitions.  The  experience  of  those  who  have  erected  model 
homes,  in  England,  particularly,  and  to  a  certain  small  extent  in  America, 
goes  to  show  that  it  is  entirely  practicable  to  put  up  separate  buildings  of  low 
cost,  but  giving  the  advantages  of  privacy,  light,  air,  and  adequate  space  to 
the  workers  housed  in  them. 


SLUMS  AND  TOWN  NUISANCES  117 

In  any  community  undertaking  to  put  in  legal  form  proper  regulations 
covering  the  erection  of  dwellings,  there  will  be  opposition  from  those  whose 
interests  are  against  the  public  welfare.  Those  who  believe  that  individual 
efficiency  is  at  the  bottom  of  national  prosperity  will  need  to  fight  hard  for 
such  laws  as  will  make  it  impracticable  to  continue  slums.  In  addition  to  the 
items  above  mentioned,  drainage,  water  supply,  the  street  surface,  the  side- 
walk, trees,  contiguous  playgrounds  for  that  recreation  absolutely  necessary 
to  the  healthy  human  animal,  and  arrangements  for  the  removal  of  human 
wastes,  must  all  be  taken  into  account. 

It  may  fairly  be  said  that  we  have  a  right  to  expect  of  the  owner  of  a 
property  that  he  shall  not  undertake  to  put  upon  it  dwellings  which  will  pro- 
duce citizens  who  must  be  cared  for  by  his  fellow  citizens  through  ill  health, 
or  immorality  resulting  from  ill  health.  It  is  also  reasonable  to  expect  that 
the  constituted  authorities  of  the  town  will  be  willing  to  enact  and  enforce 
building  laws  which  reduce  to  a  minimum  the  burden  arising  from  ill  health 
and  immorality. 

It  is  no  less  right  to  insist  that  the  tenants  of  such  buildings  as  would  be 
erected  under  the  conditions  above  described  shall  use  them  with  respect  and 
decency.  One  of  the  discouraging  things  connected  with  the  model  tene- 
ments of  New  York,  for  instance,  has  been  the  tendency  of  more  or  less 
ignorant  tenants  to  destroy  the  very  things  which  made  for  decency  and  good 
health.  The  story  of  the  Italian  woman  who  found  it  more  convenient  to 
keep  her  supply  of  kitchen  coal  in  the  bathtub  than  to  use  that  white  enam- 
elled receptacle  for  the  proper  purposes,  is  familiar  to  all.  The  tenant  must 
be  educated  in  this  matter,  and  if  he  has  been,  as  is  very  frequently  the  case, 
the  result  of  generations  of  carelessness,  it  is  going  to  be  quite  a  job  to  get  him 
to  see  the  right  and  to  do  the  right.  What,  for  instance,  could  be  expected 
of  the  children  who  have  grown  up  in  the  coal  mining  slums  of  Pennsylvania, 
under  the  shameful  conditions  there  provided  by  wealthy  owners,  if  these 
children  should  suddenly  be  given  access  to  a  properly  fitted  dwelling  house  ? 
The  responsibility  in  this  case  returns  to  the  wicked  owners  of  the  property, 
who  have  fostered  a  system  in  which  humanity  is  educated  downward  and 
returned  as  nearly  as  possible  to  barbarism. 

Manure  and  factory  refuses. —  The  time  was  when,  under  the  prevailing 
idea  that  all  that  was  necessary  was  to  get  rid  of  wastes  in  any  easy  way,  the 
housewife  deposited  the  ashes  resulting  from  her  use  of  coal  in  the  nearest 
highway,  and  the  factory  dumped  its  refuse  in  convenient  places,  taking  ac- 
count only  of  the  way  in  which  such  refuse  might  interfere  with  its  own  opera- 
tions in  respect  to  access  to  its  premises.  This  referred  primarily  to  solid 
refuse,  and  not  to  liquid  refuse,  which  was,  without  the  least  thought  of  objec- 
tion, turned  into  the  nearest  water  course. 

I  have  said  the  time  was  when  these  methods  of  disposing  of  refuse  were 
considered  proper.  I  should  say  that,  so  far  as  factory  refuse  is  concerned, 
the  time  yet  is  when,  for  the  most  part,  refuse  is  simply  gotten  out  of  the  way, 
without  consideration  of  the  neighbor.  The  housewife,  to  be  sure,  may  no 
longer  throw  potato  parings  into  the  alley,  or  ashes  into  the  street,  but  the 
manufacturer  can,  and  does,  distribute  his  refuse  without  much  reference 


118  HYGIENE 

to  his  neighbor,  taking  refuge  under  the  plea  of  the  importance  of  his  industry. 

From  the  standpoint  of  public  hygiene,  the  main  objection  to  the  thought- 
less disposition  of  stable  refuse,  here  mentioned  as  manure,  is  the  long-time 
unnoted  fact  that  the  common  house  fly  finds  its  most  favorable  breeding  place 
in  manure,  particularly  horse  manure.  Since  it  has  been  discovered  that  the 
house  fly  is  an  efficient  disseminator  of  disease  germs,  and  not  a  scavenger 
doing  good  work,  the  disposition  of  manure  becomes  distinctly  of  importance. 

Upon  the  theory  previously  indicated,  that  no  man  has  a  right  to  injure 
his  neighbor  by  any  of  his  own  acts,  manures  of  all  sorts  should  be  so  cared 
for  as  to  be  completely  inoffensive,  either  from  odor  or  as  breeding  places  for 
insects.  If  kept  in  tightly  closed  and  well-screened  pits,  and  if  hauled  away 
from  stables  in  cities  at  frequent  intervals,  and  if  these  stables  are  in  them- 
selves kept  clean,  there  should  be  little  difficulty.  If,  on  the  contrary,  there 
is  neglect  of  the  simple  sanitary  necessity  of  preventing  the  breeding  of 
injurious  insects,  by  reason  of  neglect  to  safeguard  the  handling  of  manures, 
then  a  serious  and  distinctly  dangerous  nuisance  results. 

It  has  some  bearing  on  the  subject  to  be  able  to  say  that  modern  agri- 
culturists insist  that  manures  may  properly  be  disposed  of  without  being 
subjected  to  the  process  of  rotting,  long  supposed  to  be  necessary;  that  is, 
they  may  be  promptly  put  on  the  soil,  to  return  to  it  a  portion  of  the  fertility 
extracted  through  the  processes  of  growth,  nutrition,  and  defecation. 

As  to  factory  refuses  there  can  be  no  proper  question  as  to  the  necessity 
for  insisting  that  they  be  so  cared  for  as  not  to  interfere  with  the  lives,  the 
health,  or,  indeed,  the  comfort  of  a  populace.  This  view  has  been  legally 
sustained,  particularly  in  one  notable  case,  decided  in  a  Pittsburgh  court  by 
Judge  Ewing,  when,  after  a  long  endeavor,  the  citizens  of  the  Pittsburgh 
district  known  as  Oakland  succeeded  in  securing  an  injunction  order  upon 
the  Jones  &  Laughlin  Steel  Co.,  restraining  it  from  ematting  clouds  of  ore 
dust  which  made  life  intolerable.  The  legal  view  was  put  forth  that  it  was 
not  equitable  for  the  offending  corporation  to  so  conduct  its  manufacture  as 
to  interfere  with  the  health  and  comfort  of  the  surrounding  populace,  and  that 
it  must  provide  means  for  avoiding  such  offense. 

This  would  seem  to  point  the  way  clearly  to  proper  procedure  in  respect 
to  factory  refuse,  whether  it  be  emitted  through  the  air,  deposited  on  the 
ground,  or  permitted  to  flow  into  a  water  course  by  the  usual  drainage  means. 

Latterly  the  disposition  of  health  authorities  ever}'where  is  to  insist  that 
water  courses,  said  to  belong  to  all  the  people,  shall  not  be  polluted  by  some 
of  the  people  whether  by  house  sewage  or  factory  drainage. 

There  is  another  side  to  disposition  of  factory  refuse,  not  always  taken 
up.  Great  heaps  of  slag  or  waste  from  any  manufacture,  disposed  in  careless 
fashion  and  destroying  all  vegetation,  introduces  depressing  ugliness  into  the 
landscape,  and  to  that  extent  interfere  not  only  with  comfort,  but,  indeed,  with 
health,  and  so  with  efficiency.  It  is  certainly  a  proper  view,  and  will,  I  insist, 
shortly  become  a  completely  legal  view,  that  manufacturers  must  so  arrange 
their  processes  and  methods  as  not  to  interfere  with  the  light,  air,  comfort,  or 
health  of  their  neighbors,  be  those  neighbors  their  own  workmen,  living 
nearby,  or  others  related  merely  as  fellow-citizens. 


SLUMS  AND  TOWN  NUISANCES  119 

The  positive  nuisances,  including  flies,  mosquitoes,  poles  and  wires, 
billboards,  smoke,  unnecessary  industrial  noises. —  The  house  fly  is  discussed 
elsewhere  in  this  volume,  as  also  is  the  mosquito.  Both  are  properly  classed 
as  positive  nuisances;  both  are  known  to  be  preventable,  and  the  presence 
of  both  or  either  in  any  considerable  numbers  is  disgraceful  in  any  civilized 
communit). 

As  a  disseminator  of  typhoid  and  other  diseases,  and  especially  as  con- 
nected with  its  influence  on  infant  mortalit)'  in  hot  weather,  the  house  fly  is  a 
deadly  and  desperate  menace.  The  investigations  of  the  Merchants'  Asso- 
ciation of  New  York  have  shown  that  the  infant  death  rate  in  that  great  city 
follows  closely  the  rise  of  the  number  of  house  flies.  As  the  flies  increase  the 
babies  die,  as  the  flies  die  the  babies  live;  in  my  part  of  the  subject  under 
discussion  I  need,  I  think,  only  insist  that  a  sane  view  of  public  hygiene  will 
draw  the  distinction  as  to  the  impoitance  of  lives.  If  it  is  more  important 
to  have  the  babies  of  a  community  live  than  to  have  plenty  of  house  flies, 
the  latter  must  be  killed,  or,  rather,  prevented  from  breeding. 

The  house  fly,  it  is  well  known,  breeds  only  in  filth,  particularly 
in  horse  manure,  as  has  above  been  suggested.  The  removal  of  filth  and 
the  proper  handling  of  horse  manure  will  soon  eliminate  this  dangerous 
nuisance. 

The  mosquito  is  known  in  its  various  species  to  be  the  host  and  dissemi- 
nator of  malarial  diseases,  and  in  certain  localities  of  yellow  fever  and  other 
germ  diseases.  It  is  known  also  to  breed  only  in  stagnant  water,  and  its 
presence  in  any  community  is  an  evidence  of  sanitary  neglect.  The  success 
which  has  followed  energetic  endeavor  to  free  from  mosquitoes  —  both 
malarial  and  ordinary'  —  certain  localities  on  Long  Island  and  in  New  Jersey 
shows  that  a  ny  community  can  be  rid  of  this  buzzing  nuisance.  It  is  not  amiss 
to  mention  that  of  the  thirty  odd  species  of  mosquito  known  to  exist  in  the 
Eastern  states,  but  one  or  two  fly  to  any  considerable  distance.  Breeding 
places  may  therefore  best  be  looked  for  immediately  about  the  premises 
aflfected.  A  hoof  print,  a  choked  roof  gutter  or  rain  spout,  a  discarded  tin 
can,  or  any  little  puddle  may,  in  a  week  or  two  in  hot  weather,  aff^ord  breeding 
opportunity  to  a  horde  of  off^ensive  mosquitoes.  To  screen  the  house  is  an 
excellent  method  of  defense,  but  a  better  method  is  to  prevent  the  breeding 
of  the  mosquito  by  drying  up  the  stagnant  pools,  wherever  they  may  be  found, 
in  which  he  loves  to  generate,  or  by  covering  with  a  thin  film  of  petroleum  the 
water-holding  vessels  which  cannot  be  otherwise  treated,  thus  killing  the 
wigglers  as  they  rise  to  the  surface  to  breathe,  and  hy  generally  seeing  to  it 
that  the  necessary  conditions  for  mosquito  life  are  not  provided. 

It  is  a  mistake  to  insist  that  trees  or  shrubbery  aff^ord  breeding  places  for 
mosquitoes.  This  is  in  no  case  true,  but  it  is  true  that  when  mosquitoes  have 
been  bred  somewhere  through  the  provision  of  the  necessary  stagnant  water, 
the  trees  and  shrubs  afi^ord  comfortable  lurking  places  for  them. 

I  class  electric  poles  and  wires  as  among  the  positive  nuisances  of  town 
life.  They  obstruct  the  view,  and  while  their  relation  to  hygiene  is  only  that 
which  comes  about  as  one  considers  that  they  interfere  with  ultimate  effi- 
ciency, yet  their  removal  gives  so  much  greater  freedom,  atmosphere,  and 


120  HYGIENE 

beauty  to  our  community,  streets,  and  roadways,  that  they  may  properly  be 
classed  as  nuisances. 

The  increasing  price  of  timber,  and  the  fact  that  the  maintenance  of  an 
overhead  wire  line  is  far  more  expensive  than  the  maintenance  of  an  under- 
ground line,  tend  to  decrease  this  nuisance.  It  is  believed  that  in  the  course 
of  time  main  lines  of  wire  throughout  the  country,  as  well  as  in  populous 
communities,  will  be  put  under  ground,  effecting  a  great  improvement  in 
conditions  generally,  as  well  as  a  vast  economy  in  maintenance. 

The  billboard  is  classed  as  a  positive  nuisance  for  several  reasons.  As 
erected  in  most  of  the  smaller  communities,  without  adequate  supervision, 
it  tends  to  afford  places  for  the  depositing  of  filth  behind  its  outer  surface, 
and  in  many  cases  affords  convenient  opportunity  for  lawless  persons  to 
commit  other  nuisances.  Where  billboards  must  be  permitted  there  should 
be  a  positive  regulation  that  they  be  maintained  at  not  less  than  two  feet  from 
the  surface  of  the  ground  on  which  they  stand,  and  that  the  owner  of  the 
property  on  which  they  are  maintained  be  charged  with  the  duty  of  keeping 
the  ground  back  of  them  absolutely  free  from  anything  offensive  to  the  senses. 

Billboards  are  a  nuisance  also  because  they  tend  to  education  in  vulgar- 
ity, in  bad  form,  in  incongruous  coloring,  and,  in  general,  toward  the  very 
opposite  to  that  which  makes  for  efficiency.  The  restfulness  of  natural 
scenery  is  recognized.  No  one  has  ever  insinuated  that  when  the  landscape 
is  substituted  by  a  "  billboard  scape  "  restfulness  is  present  at  all.  Who  has 
not  seen  the  traveler  turn  his  weary  eyes  from  the  once  restful  landscape  to 
the  inside  of  the  car  in  which  he  was  traveling  because  of  the  assaults  upon 
his  optic  nerves,  created  by  a  succession  of  staring  announcements  of  whisk- 
eys, corsets,  phonographs,  tobacco,  and  nostrums  ? 

Billboards  are  a  positive  nuisance  also  because  they  are  a  positive  waste. 
Tests  are  shown  that  the  effectiveness  of  billboards  as  a  means  of  advertising 
is  very  low.  Inasmuch  as  it  is  impossible  for  advertisers  to  trace  results, 
those  who  erect  billboards  secure  their  continuance  mainly  by  an  appeal  to 
improbable  advantages. 

It  is  believed  that  before  a  great  while  the  courts  will  class  billboards  as 
nuisances  under  the  common  law,  and  that  they  will  either  be  abolished,  for 
the  most  part,  or  restricted  to  definite  localities,  to  definite  sizes,  and  to  less 
offensiveness.  In  the  city  of  Cincinnati  the  new  building  code  restricts  them 
to  not  exceeding  twelve  feet  in  height  or  thirty  feet  in  length,  and  provides  a 
definite  interval  between  two  billboards.  They  are  compelled  also  to  keep 
at  least  two  feet  from  the  ground  and  to  keep  back  at  least  ten  feet  from  the 
street  line  of  any  property  on  which  they  may  be  erected.  In  Kansas  City 
residents  may  secure  the  condemnation  of  billboards  right  in  any  district, 
with  compensation  by  the  city  to  owners  of  property  under  consideration, 
so  that  billboards  may  be  completely  eliminated.  Efforts  are  being  made  in 
many  cities  and  states  to  tax  the  billboards,  and  thus  to  diminish  their  in- 
trusions. 

Smoke  is  unquestionably  one  of  the  greatest  of  the  positive  nuisances. 
It  is  just  as  unquestionably  one  of  the  least  necessary  of  these  positive  nui- 
sances.    Nearly  all  the  black  smoke  emitted  over  our  communities  is  com- 


SLUMS  AND  TOWN  NUISANCES  121 

posed  of  unconsumed  carbon,  unreplaceable,  and  having  a  very  distinct 
relation  to  our  vanishing  coal  supply.  It  would  seem  to  be  no  more  right  for 
the  manufacturer  to  deposit  his  carbon,  carelessly  emitted  through  the  stack 
over  his  boiler  furnace,  upon  the  persons,  clothing,  and  goods  of  his  neighbor 
than  it  is  for  the  housewife  to  deposit  her  ashes,  which  are  the  result  of  her 
combustion  of  carbon,  on  the  sidewalk  or  in  the  street. 

Statistics  show  that  vast  damage  in  a  material  way  results  from  the 
emission  of  black  smoke.  Something  more  than  two  hundred  million  dollars 
a  year  is  the  economic  waste  In  the  United  States,  according  to  a  recent  report 
made  by  a  section  of  the  Federal  Geological  Survey. 

From  the  hygienic  standpoint,  black  smoke  is  certainly  a  nuisance  and  a 
damage.  It  clogs  the  human  air  passages  and  the  lungs,  and  is  known  to 
decrease  life  and  to  have  an  injurious  effect  in  many  disorders. 

The  emission  of  black  smoke  is  totally  unnecessar}'.  Vv  ith  the  provision 
of  a  proper  furnace  any  sort  of  coal  may  be  burned  without  black  smoke. 
It  is  not  necessary  that  the  details  of  proper  combustion  shall  be  here  dis- 
cussed, but  it  may  be  briefly  noted  that  the  main  essential  for  proper  combus- 
tion is  the  provision  of  ample  space  between  the  fire  and  the  boiler,  or  other 
surface  to  be  heated,  in  which  the  gases  resulting  from  the  burning  of  the  coal 
may  be  fully  consumed  before  they  strike  the  colder  surface  of  the  boiler  or 
other  object  above,  and  are  thus  condensed  into  form  to  be  emitted  as  black 
smoke.  There  are  numberless  devices  on  the  market,  many  of  which  are  effi- 
cient, but  no  device  works  in  the  absence  of  intelligent  attention  by  the  fire- 
man, himself  usually  the  worst  paid  and  most  carelessly  treated  employee  in 
any  manufacturing  plant. 

Communities  should  prepare  to  enforce  reasonably  restrictive  laws 
against  the  emission  of  black  smoke,  providing  an  inspector  to  see  that  manu- 
facturers obey  the  law,  and  proposing  progressive  penalties,  under  which  it 
will  be  most  expensive  for  manufacturers  to  persist  in  creating  this  nuisance. 

It  is  known  that  any  grade  of  coal  burned  in  a  suitably  constructed  fur- 
nace will  give  a  far  greater  degree  of  its  latent  force  to  the  use  of  the  manu- 
facturer than  if  improperly  burned.  There  is  therefore  hope  that  good  sense 
will  supervene,  especially  in  connection  with  reasonably  restrictive  laws,  to 
bring  about  the  practical  abolition  of  wasteful  black  smoke. 

The  use  of  electric  power,  generated  in  large  volumes  under  conditions 
which  make  the  emission  of  smoke  notably  uneconomical,  or  generated  from 
water  power,  will  obviously  tend  to  reduce  the  emission  of  smoke  in  com- 
munities, and  the  eventual  electrification  of  railroads  may  be  expected  to 
solve  the  most  difficult  part  of  the  smoke  problem. 

Unquestionably  unnecessary  industrial  noises  have  a  distinct  relation  to 
the  health  of  the  people,  and  thus  come  into  proper  consideration  in  a  volume 
devoted  to  modern  hygiene.  I  refer  under  this  designation  to  the  passing  of 
trolley  cars  with  what  are  technically  known  as  "  flat  wheels,"  or  with  ill- 
adjusted  machinery,  making  a  frightful  racket;  to  the  continuance  of  cobble- 
stone or  Belgian  block  street  paving,  over  which  heavy  teams,  loaded  with 
carelessly  packed  noise-producing  wares,  are  driven  by  shouting  and  often 
profane  teamsters;   to  the  unnecessary  ringing  of  bells  and  blowing  of  whis- 


122  HYGIENE 

ties;  to  the  reducible  noise  met  with  contiguous  to  great  factories;  and,  in 
short,  to  all  other  forms  of  waste  and  friction  which  produce  racket,  clangor, 
and  nerve-distracting  sounds. 

There  is  evidence  easily  obtainable  to  showthat  any  normal  human  being 
works  with  greater  efficiency  amid  surroundings  of  reasonable  quietude. 
Leaving  out  of  consideration  for  the  moment  the  effect  of  these  industrial 
noises  on  persons  ill  or  in  a  subnormal  condition,!  insist  that  unnecessary  and 
avoidable  noises  directly  reduce  the  working  efficiency  of  every  human 
being  exposed  to  them,  and  that  for  that  reason,  if  for  no  other,  they  should  be 
comhatted,  reduced,  and,  as  far  as  possible,  eliminated.  I  believe  that  the 
prevailing  racket  characteristic  of  American  cities  can  be  reduced  fully 
seventy-five  per  cent,  with  an  added  increase  in  efficiency  due  to  the  resulting 
peace  which  will  far  more  than  compensate  for  the  cost  involved. 

It  is  admitted  that  sound  sleep  is  necessary  if  the  tired  worker  is  to  be 
restored  to  efficiency.  Sound  sleep  is  impossible  if  the  local  authorities  permit 
rackety  trolley  cars  to  pound  through  the  streets  without  respect  to  the  noise 
created,  at  all  hours  of  the  night,  ringing  their  exciting  gongs  at  frequent 
intervals,  sometimes  in  accordance  with  city  regulations,  but  without  real 
necessity.  That  these  noises  are  reducible  ought  to  be  evident  to  an}  one  who 
reflects  on  the  difference  between  the  automobile  of  to-day,  so  noiseless  as  to 
give  no  signal  of  its  approach,  except  when  its  noise-producing  device  is 
operated,  as  compared  with  the  unpleasant  racket  characterizing  the  auto- 
mobile of  but  a  few  years  ago.  If  noise  can  be  eliminated  from  the  auto- 
mobile, a  mechanism  operated  on  indifferent  and  miscellaneous  roads,  it  can 
certainly  be  eliminated  from  trolley  cars,  whose  mechanism  operates  on  rail- 
ways, which  surely  can  be  made  smooth,  and  ought  to  be. 

The  other  mechanical  noises  referred  to,  connected  with  paving,  teaming, 
and  factory  work,  can  certainly  be  removed  almost  entirely  by  proper  atten- 
tion, and  such  removal  should  be  insisted  upon  as  a  necessary  adjunct  to 
wholesome  life. 

The  blowing  of  whistles  is  a  barbarous  survival  of  the  day  when  there 
were  no  clocks.  Any  manufacturer  can,  at  slight  expense,  install  electric 
gongs  about  his  premises,  which  will  give  signals  for  commencing  and  stop- 
ping work  without  alarming  the  neighborhood.  Particularly  does  this  sug- 
gestion apply  in  the  cases  still  existing  in  which  whistles  are  used  in  the  small 
hours  of  the  morning  to  arouse  those  unfortunates  who  must  take  up  their 
labors  at  early  hours.  It  is  obviously  unfair  to  awaken  an  entire  neighbor- 
hood in  order  that  a  score  or  more  of  workers  may  be  caused  to  disregard  the 
easily  obtainable  alarm  clock. 

An  unnecessary  noise  has  been  above  alluded  to  in  the  explosive  gong  of 
the  trolley  car,  which,  as  I  have  before  said,  is  sometimes  by  municipal  ordi- 
nance operated  at  every  street  crossing.  To  substitute  sharp  vigilance  on  the 
part  of  the  motorman  would  be  to  relieve  the  community  from  this  unneces- 
sary addition  to  its  preventable  noises. 

The  operations  of  railroads  produce  many  avoidable  noises.  Whistling 
can  be,  and  in  some  American  communities  is,  reduced  to  a  minimum,  being 
done  only  for  necessary  signalling  purposes  and  in  cases  of  danger. 


SLUMS  AND  TOWN  NUISANCES  123 

There  is  a  class  of  noises  not  connected  with  industrial  life,  for  the  con- 
tinuance of  which  there  is  absolutely  no  excuse.  I  refer  particularly  to  the 
periodic  celebration  of  the  national  holiday,  through  the  explosion  of  fire- 
works, guns,  and  pistols.  From  every  standpoint  this  misuse  of  the  national 
holiday  is  wrong.  That  it  has  annually  caused  a  great  sacrifice  in  life, 
property,  and  in  addition  caused  many  accidents,  does  not  seem  yet  to  have 
impressed  the  public  as  to  the  futility  of  this  form  of  showing  patriotism. 
But  it  is  believed  that  eventually  a  "  safe  and  sane  Fourth  "  will  prevail  in 
the  United  States,  to  the  comfort  of  many,  particularly  those  who  may  be  at 
that  time  so  unfortunate  as  to  be  confined  in  hospitals  or  their  homes  by  illness. 

The  whole  matter  may  be  summed  up  in  the  statement  that  every  avoid- 
able noise  of  a  distracting  character  is  unhygienic  and  wrong,  and  in  the 
properly  conducted  city  such  noises  will  be  suppressed  or  reduced. 

Sewers,  sewage  disposal  and  purif cation. —  This  subject  relates  only 
remotely  to  that  of  the  chapter.  The  absence  of  sewers  undoubtedly  creates 
a  nuisance,  and  therefore  I  may  briefly  insist  that  a  proper,  modern,  well- 
designed  and  successfully  operated  system  for  removing  the  wastes  of  human 
life  is  essential  in  any  decent  community.  Just  what  that  method  is  to  be 
must  be  determined  in  each  individual  instance.  It  is  no  longer  considered 
right  to  dispose  of  these  human  wastes  by  turning  them  into  a  convenient 
water  course,  as  I  have  before  observed,  and  therefore,  in  addition  to  such 
division  of  liquid  wastes  as  will  keep  house  sewage  distinct  from  storm 
water  and  street  drainage,  there  needs  to  be  taken  up  in  any  community 
some  adequate  system  of  sewage  disposal  and  possibly  of  purification. 

The  subject  may  properly  be  dismissed  for  consideration  in  a  more  com- 
pletely technical  way  by  reiterating  the  statement  that  no  community  has  the 
right  to  thrust  the  unsanitary  result  of  the  wastes  of  its  own  life  either  upon  its 
own  citizens  or  upon  the  citizens  of  another  community. 

Stagnant  water. —  The  main  reason  for  disposing  of  stagnant  water  is 
that  it  is  in  it  that  the  mosquito  breeds.  A  secondary  reason  is  that  a  pond 
or  puddle  of  stagnant  water  seems  inevitably  to  attract  tin  cans  and  refuse 
which  tends  to  become  much  more  unsanitary  than  the  water  itself. 

A  general  misconception  exists  in  regard  to  stagnant  water  with  a  green 
scum.  This  scum  is  plant  life,  and  is  not  unwholesome  in  itself;  indeed,  it 
frequently  takes  up  through  the  process  of  nature  impurities  in  the  water^ 
which  are  thus  turned  through  nature's  economics  to  what  may  be  a  useful 
purpose. 

Unquestionably  stagnant  water  should  usually  be  drained.  Where  it 
cannot  be  conveniently  drained  a  thin  film  of  a  mineral  oil  will  at  least  prevent 
the  breeding  of  mosquitoes. 

Public  dumps. —  These  seem  to  be  necessary  in  modern  community  eco- 
nomics. They  also  seem  to  be  usually  unsanitary,  and  they  tend  continu- 
ously to  become  public  nuisances.  Where  the  dumping  is,  as  is  often  ideally 
proposed,  of  clean  ashes  only,  there  can  be  no  harm  done  and  no  nuisance 
created.  When,  however,  a  disgusting  odor  comes  from  a  dump  upon  which 
supposedly  nothing  but  clean  ashes  have  been  placed,  obviously  somebody 
has  gone  wrong.     In  practice  dumps  are  always  odorous,  and  should  have^ 


124  HYGIENE 

for  that  reason,  sharp  attention.  Where  there  is  a  garbage  collection  system, 
and  especially  where  there  is  some  attempt  to  economically  recover  value  from 
house  wastes  deposited  in  garbage  cans,  it  is  certainly  practicable  to  reduce  the 
dump  to  its  lowest  oftensiveness.  This  can  be  accomplished  by  rigid  inspec- 
tion, following  a  proper  basic  contract  or  set  of  rules,  under  w^hich  offensive 
conditions  bring  immediate  and  automatic  punishment  in  the  way  of  penalties 
or  fines. 

The  depositing  of  loose  papers,  boxes,  and  the  like  on  public  dumps 
intended  for  clean  ashes  only  creates  a  nuisance,  not  necessarily  unsanitary, 
but  none  the  less  annoying.  There  is  no  reason  for  the  continuance  of  any 
such  nuisance. 

As  to  the  success  of  garbage  reduction  operations  I  cannot  speak  with 
assurance.  Thev  exist  in  many  places,  and  their  existence  is  generally  r^bvious 
to  the  entire  neighborhood  because  of  their  failure  to  maintain  the  scentless 
condition  upon  which  they  usually  secure  entrance  to  that  neighborhood. 
That  there  is  material  of  money  value  in  the  wastes  of  life  which  are  collected 
as  garbage,  and  which  tend  to  get  on  public  dumps,  is  known.  In  New  York 
and  in  other  large  cities  considerable  revenue  is  received  from  attention  to  this 
class  of  substances.  The  burning  of  loose  refuse  under  boilers  to  create 
power  is  successfully  practiced  in  New  York,  where  one  large  bridge  is  lighted 
entirely  from  loose  garbage  consumed  in  this  fashion. 

The  whole  subject  of  public  dumps  and  garbage  handling  is  at  this 
writing  not  at  all  in  a  settled  and  definite  condition.  There  is  much  dis- 
cussion and  experimientation,  and  there  will  eventually  ensue  a  sanitary  result. 

The  disposition  of  factory  and  manufacturing  refuse  has  been  above 
alluded  to.  It  has  a  relation  to  dumps,  however.  In  localities  where  it  is 
desirable  to  fill  in  low  places,  clean  factory  refuse  is  certainly  usable  to  advan- 
tage. There  should  never  be  any  offensive  manufacturing  refuse  dumped 
anywhere,  for  under  the  construction  I  assume  as  the  basis  of  this  chapter,  no 
manufacturer  has  the  right  to  ask  his  neighbor  to  suffer  from  or  take  care  of 
the  results  of  his  industry  or  carelessness. 

The  dumping  of  mine  refuse  on  the  banks  of  streams  or  its  washing  into 
water  courses  is  receiving  considerable  attention.  In  connection  with  our 
vanishing  coal  supply  this  frequently  combustible  refuse  will  diminish,  as 
it  becomes  necessary  and  desirable  to  utilize  it  for  the  unconsumed  carbon  it 
contains.  Meanwhile  it  is  not  improper  to  assume  the  position  common  to 
other  details  of  this  subject,  that  the  mine  owner  has  no  more  right  than  any 
other  citizen  to  reduce  the  pleasantness  and  efficiency  of  the  lives  of  his  em- 
ployees and  his  neighbors  by  depositing  his  refuse  where  it  will  act  to  that 
result  than  any  other  citizen  has  to  do  the  same  things. 

Dirty  backyards  and  vacant  lots. —  Unquestionably  filth  in  backyards 
and  in  vacant  lots  is  a  potent  means  of  continuing  the  slum  and  creating  a 
town  nuisance.  Under  the  American  idea  of  the  sacredness  of  private  prop- 
erty the  disposition  to  allow  the  individual  to  do  what  he  pleases  on  his  own 
premises  has  given  rise  to  filthy  conditions.  With  the  modern  conception  of 
the  responsibility  of  the  individual  to  his  fellows,  and  under  the  broad  scope 
of  the  police  power  of  the  community,  it  is  certainly  practicable  to  prohibit 


SLUMS  AND  TOWN  NUISANCES  125 

the  collection  of  filth  or  material  of  an  unsanitar}-  nature  close  to  human  habi- 
tations, and  to  have  it  removed  at  the  cost  of  the  offender,  where  it  has  been 
deposited. 

A  little  attention  en  the  side  to  the  promoting  knowledge  of  the  desira- 
bility of  the  use  of  plants,  fiowei's,  and  trees  in  back}ards  sufficiently  open  to 
the  sun  and  air  for  their  growth  will  often  entirely  remove  the  trouble  from 
unpleasant  backjards.  Any  movem.ent  in  a  town  which  will  stimulate  the 
pride  ot  the  citizen  in  his  own  surroundings  and  about  his  own  hom.e  will  help 
amazingly  in  eliminating  the  dirty  backyard.  There  exist  in  many  communi- 
ties societies  distributing  free  or  at  a  nominal  price  seeds  of  flowers  and  vege- 
tables, for  the  successful  growth  of  which  premiums  are  offered.  Particularly 
in  Cleveland,  Ohio,  the  long  pursuit  of  this  plan  has  been  effective  in  almost 
eliminating  the  unpleasant  backyard. 

Dirty  vacant  lots  should  be  eliminated  under  the  police  power  of  the 
community  by  requiring  the  owner  of  them  to  make  his  premises  sanitary  and 
sightly.  It  may  be  that  he  cannot  be  legally  forced  to  make  them  sightly, 
for  as  yet  the  police  power  does  not  protect  the  eye.  It  is  certain  that  he  can 
be  compelled  to  keep  them  sanitary.  Therefore,  when  a  vacant  lot  becomes  a 
dumping  ground  for  refuse,  slyly  placed  there  by  citizens  who  know  better, 
the  municipal  authorities  should  take  action  to  either  catch  the  offenders 
in  the  act  or  force  the  owner  of  the  lot  to  himself  protect  his  own  property. 

In  some  communities  much  good  has  resulted  from  a  movement  to  place 
vacant  lots,  upon  which  vegetables  might  be  grown,  at  the  disposition  of  men 
out  of  work  or  of  men  who  could  so  use  spare  time.  There  immediately  en- 
sues good  order  and  pleasant  experience,  as  well  as  a  real  addition  to  the 
wealth  of  the  community,  not  only  in  the  value  of  the  products  raised,  but  in 
the  knowledge  obtained  and  in  the  economics  promoted. 

Frequently,  therefore,  the  suggestion  that  vacant  lots  may  thus  be  availed 
of  will  work  a  removal  of  what  may  be  a  distinct  nuisance. 

Where  vacant  lots  are  used  to  harbor  billboards  the  observations  pre- 
viously made  in  respect  to  this  outbreaking  nuisance  may  be  taken  into 
account.  I  urge  the  consideration  of  the  fact  that  in  such  an  event  as  the 
erection  of  a  billboard  on  a  vacant  lot  it  shall  be  construed  by  assessors  as 
liable  for  taxes,  and  that  it  may  no  longer  be  considered  a  vacant  lot,  inasmuch 
as  a  structure  has  been  erected  on  it,  properly  subject  to  taxation  supervision 
and  the  necessity  for  preserving  sanitary  conditions.  Such  a  public  sentiment 
in  the  community  as  will  force  the  assessors  and  health  authorities  to  thus 
look  after  the  billboards  will  eliminate  some  of  them  and  certainly  promote 
the  public  welfare  in  several  obvious  ways. 

Conclusion. —  In  discussing  this  whole  problem  of  slums  and  town 
nuisances  I  have,  as  will  be  observed,  considered  the  matter  from  a  rather 
broad  humanitarian  standpoint,  avoiding,  for  the  most  part,  definite  direc- 
tions, and  trying  to  state  as  well  as  I  may  the  determining  principles  which 
relate  the  subject  under  discussion  to  public  hygiene.  I  do  not  believe  the 
cause  of  public  health  can  be  advanced  in  any  way  so  well  as  in  bringing  about 
a  feeling  that  every  man  is  responsible,  not  only  for  his  own  acts,  but  for  the 
influence  of  those  acts  upon  his  neighbors,  whether  that  influence  arises 


126  HYGIENE 

through  noises  he  makes,  through  smoke  or  refuse  he  puts  upon  his  neighbors, 
through  unsanitary  conditions  he  creates,  through  land  greed  or  the  erection 
of  improper  dwellings,  or  through  any  other  act  which  makes  less  wholesome, 
happy,  and  therefore  efficient,  the  lives  of  his  fellow-citizens. 

Notes. —  In  addition  to  the  matters  discussed  by  Mr.  McFarland,  sewers,  the  fly 
nuisance,  mosquitoes  as  carriers  of  infection,  weeds,  factory  wastes,  the  garbage  pro- 
blem, and  other  town  nuisances  are  discussed  in  several  other  chapters.  (See  the  gen- 
eral index.)  Mr.  McFarland  has  asked  the  editor  to  say  something  about  bubonic 
plague  and  the  town  nuisances  contributing  to  its  spread.  The  extensive  spread  of 
the  disease  during  the  last  few  years  has  led  to  a  large  volume  of  literature  upon  the 
subject  and  what  I  have  to  say  will  be  very  brief 

In  the  1908  Weekly  Public  Health  Reports  appears  a  paper  prepared  by  direc- 
tion of  che  Surgeon-General  and  that  shows  the  total  number  of  countries  infected 
since  1894  to  be  51,  and  with  a  dreadful  mortality,  India  in  1907  having  1,400,000 
cases  and  1,200,000  deaths.  The  personal  prophylaxis  being  rigid  quarantine  and 
the  avoidance  of  contact  with  rats,  dogs,  and  other  flea-carrying  animals,  ground 
squirrels,  etc.  It  is  stated  that  coal  oil  best  protects  against  the  fleas.  Quarantine 
against  rats  is  an  important  matter  and  vessels  must  anchor  at  least  a  third  of  a  mile 
from  port  if  considered  infected.  Sulphur  fumigation  is  used  aboard  for  the  destruc- 
tion of  rats  and  bacteria. 

Cities  and  houses  infected  require  most  elaborate  disinfection  and  such  measures 
as  will  render  them  rat  proof.  This  is  accomplished  principally  by  cement  or  concrete 
construction  of  walls  and  portions  near  to  the  ground.  All  sources  of  food  for  the  rats 
must  be  cut  off  except  such  as  is  poisoned  and  set  for  them.  This  involves  very  care- 
ful garbage  collection  and  destruction.  In  California,  ground  squirrels  are  known 
to  have  caused  nearly  all  of  the  recent  cases,  and  it  is  possible  that  other  squirrels  carry 
the  disease.  In  view  of  this,  it  appears  unwise  to  harbor  squirrels  in  parks  or  to  eat 
their  flesh  in  sections  known  to  be  infected.  The  squirrel  readily  domesticates.  From 
the  adjoining  parks  these  animals  are  spreading  all  over  this  city  and  they  frequently 
enter  yards  and  even  houses  here.  This  is  a  potential  danger  when  the  least  infection 
exists. 

Outgoing  quarantine  involves  the  disinfection  of  all  clothing,  rags,  etc.,  and  the 
utmost  care  in  receiving  and  loading  vessels  and  cars.  Wharves  should  be  provided 
with  rat  funnels  and  proper  fenders,  and  the  gangways  should  be  elevated  six  feet  above 
the  wharves  at  night. 

Sewers  should  be  especially  watched  and  placed  in  the  best  possible  condition  in 
order  to  prevent  their  harboring  rats. 

Trapping  and  poisoning  rats  has  been  reduced  to  a  science  in  San  Francisco  and 
other  infected  places.  The  large  nineteen-inch  French  wire  cage  trap  is  preferred, 
but  must  be  made  of  heavy  wires.  The  best  places  to  set  them  are  slaughter  houses, 
meat  markets,  chicken  houses,  cellars,  and  near  to  the  garbage  cans.  Traps  must  also 
be  set  in  the  sewers  and  the  habits  of  the  rodents  must  be  studied  to  secure  the  best 
results.  The  bait  may  be  one  of  many  substances  rats  like,  but  are  not  likely  to  obtain 
where  the  rat  trap  is  set.  A  female  ra.  within  the  trap  is  likely  to  attract  males  and  the 
young.  Kill  the  rats  where  live  ones  cannot  hear  them  squeal  and  burn  out  the  trap 
before  setting  again.  Rats  may  be  poisoned  by  arsenic,  phosphorus  paste,  and  car- 
bonate of  baryta.  In  the  city  of  San  Francisco  it  is  estimated  that  800,000  rats  have 
been  trapped  and  poisoned  since  1907. 


Chapter  VIII 
SPECIAL  RURAL  HYGIENE  AND  SANITATION* 

Watersheds  and  rural  water  supply — Ice  supply  and  ice  ponds — Infected  wells — 
Spring — Cisterns  —  Hauled  water  —  Tanks  and  piped  water — Barnyard  drainage — 
Sewage  —  Vaults  -^-  Fertilizers  —  Sick  and  dead  animals  ^ —  Milk  supply  and  the  many 
questions  involved  therein  —  Cheese,  meat,  and  milk  ptomaines — Butter  and  butter 
substitutes — Creameries — Dressed  meats  and  federal  inspection — Poultry — Eggs — 
Food  preservatives  and  dyestufFs  —  Fish  and  game  meats — Insecticides  upon  food — 
Poisonous  plants  and  their  eradication  —  Insect  pests  —  Sanitation  in  sending  produce 
to  market  —  Summer  camps  —  Rural  resorts. 

AS  means  of  communication  increase  and  the  country  settles  up,  the 
special  problems  of  rural  and  urban  hygiene  disappear  and  the  work 
of  state  medicine  is  making  one  question  of  the  whole.  There  is  no 
just  reason  for  considering  the  farmer  as  peculiar  or  possessed  of  special 
privileges  or  immunities;  nor  is  it  right  to  create  distinctions  between 
urban  and  rural  dwellers  or  establish  lines  of  procedure,  in  sanitation,  apply- 
ing exclusively  to  one  or  the  other  class.  But  there  are  matters  of  detail 
and  environment  and  practical  points  in  the  farmer's  busmess  that  demand 
consideration  the  same  as  any  other  business  or  industry.  A  full  treatise 
upon  rural  hygiene  would  demand  a  volume  of  itself,  but  it  may  be  said  that 
nearly  every  chapter  of  this  present  book  bears  directly  upon  some  phase  of 
the  problem  facing  the  ruralist,  and  what  will  be  said  herein  will  treat  of  the 
special  sanitary  measures  from  a  practical  point  of  view  and  from  that  of  one 
who  used  to  be  "  a  country  doctor." 

Watersheds  and  rural  water  supply. —  Although  the  general  question  of 
water  supply  is  treated  of  in  Chapter  XXII,  some  data  must  be  given  here  in 
order  to  understand  the  importance  of  a  watershed.  Rain  water  is  nearly 
chemically  pure,  except  for  impurities  in  the  air  carried  down  by  the  first 
portion  of  the  rainfall.  These  impurities  vary  greatly  and  may  contain  con- 
siderable organic  and  bacterial  matter,  but,  taken  as  a  whole,  the  total  pre- 
cipitation is  quite  pure  at  the  moment  it  falls  upon  the  earth.  But  such  soft 
water  is  a  rapid  solvent,  and  not  only  carries  into  solution  many  of  the  chemi- 
cal substances  in  the  soil  and  the  rock  strata,  but  by  virtue  of  its  contained 
oxygen  gas  and  ammonia,  it  acts  chemically  and  produces  hydrates  and  ox- 
ides. In  the  earth  it  takes  up  carbonic  acid,  and  that  in  turn  produces  other 
chemical  changes.  In  sandy  soil  there  is  very  little  carbonic  acid.  There  is 
no  substantial  ground  for  the  view  that  melted  snowwater,  from  clean  regions, 
is  more  impure  than  is  rainwater. 

For  these  reasons  much  ground  water  is  not  fit  for  domestic  use,  aside 
from  later  contamination.  Arid  plains,  alkaline  deserts,  country  underlaid 
with  sulphides,  arsenic,  and  other  toxic  minerals,  gas,  and  oil,  and  even  some 
kinds  of  limestone,  all  yield  water  either  partially  or  wholly  unfit  for  use. 

*Prepared  from  numerous  reports  and  investigations  of  agricultural,  dairying, 
and  government  organizations  and  departments. 


128  HYGIENE 

Settlers  in  new  country  should  carefully  examine  into  the  water  supply. 
Sulphur  waters  should  be  used  cautiously,  as  they  are  reputed  to  cause 
exotoses  in  cattle  and  other  diseases  of  bone  in  man.  Calculi  may  be  caused 
by  limestone  waters,  while  goitre  may  arise  from  the  constant  use  of  mag- 
nesian  and  sedimentous  waters.  All  this  goes  to  show  the  importance  of  the 
watershed  from  a  chemical  point  of  view.  I  would  advise  farmers  to  be  care- 
ful about  signing  oil  and  gas  leases  covering  their  farms,  since  the  sinking  of 
wells  may  result  in  striking  salt  water,  which  is  pumped  or  runs  over  the  land, 
thus  permanently  ruining  the  soil. 

Natural  organic  impurities  need  not  occasion  much  alarm.  Nature 
maintains  a  balance  and,  except  in  marshy  and  tropical  lowlands,  these 
impurities  are  not  especially  dangerous.  Country  spring  water  contains 
little  organic  impurities,  few  bacteria,  and  a  mere  trace  of  albuminoid  am- 
monia. Dead  organic  matter  does  not  markedly  influence  the  health,  but  its 
presence  (as  shown  by  the  permanganate  test)  may  be  a  valuable  indication 
of  the  presence  of  pollution.  Hence,  until  water  is  shown  to  contain  no 
dangerous  impurities,  it  is  a  safe  rule  to  suspect  all  water  containing  much 
organic  matter.  There  is  a  vast  difference  between  natural  organic  impuri- 
ties and  organic  pollution.  Even  the  fact  that  a  water  contains  many  bacteria 
does  not  indicate  marked  danger  unless  it  is  some  specific  and  pathogenic 
bacterial  contamination.  Very  deep  wells  usually  yield  pure  water,  but  not 
always.  My  neighbor.  Dr.  Harvey  B.  Bashore,  says  truly,  in  his  book,  "  The 
Sanitation  of  a  Country  House  " : 

A  spring,  like  many  other  things  in  this  world,  is  just  as  good  as  its  surroundings. 
If  it  happens  to  be  situated  on  an  uninhabited  and  uncultivated  upland  it  will  likely 
yield  a  pure  water,  and  if  near  enough  and  constant  enough  may  furnish  the  most 
available  supply,  especially  if  it  is  at  such  an  elevation  that  it  can  be  used  by  a  gravity 
system. 

Since  springs  are  only  overflows  of  the  ground  water,  their  condition  is  dependent 
on  the  geological  character  of  the  strata  through  which  the  water  passes.  In  a  region 
in  which  the  strata  have  been  upturned  and  broken  there  may  be  a  seepage  of  pollu- 
tion from  places  little  suspected,  unless  one  is  thoroughly  conversant  with  the  place. 

In  a  limestone  region,  on  account  of  the  many  underground  seams  and  tunnels 
which  transmit  wacer  with  great  facility,  without  the  filtering  properties  of  the  soil, 
pollution  and  infection  may  travel  for  miles. 

Therefore,  these  small  streams  and  springs  are  the  most  liable  to  danger- 
ous contamination,  and  none  should  be  used  for  a  water  supply  until  after  it  is 
followed  up  to  its  source  and  its  watershed  well  examined.  It  is  these  small 
watersheds  that  are  of  the  greatest  importance  to  the  farmer  and  contami- 
nation is  not  diluted  largely  by  them.  One  case  of  typhoid  on  such  a  shed 
may  infect  a  whole  neighborhood. 

Watersheds  on  a  larger  scale  interest  the  whole  country  and  are  quite  a 
problem.  Too  big  a  problem  for  any  one  short  of  the  state  itself.  Chapter 
IX  discusses  this  matter,  while  specific  contamination  of  waterways  and 
public  supply  is  adequately  presented  under  appropriate  headings.  Undoubt- 
edly the  best  way  to  be  prepared  for  the  emergencies  arising  from  contamina- 
tion of  the  watersheds  is  for  the  state  to  prepare  maps  from  sanitary  surveys 


SPECIAL  RURAL  HYGIENE  129 

and  from  the  geologic  data,  of  every  waterway  in  the  state  and  of  every  build- 
ing upon  the  watersheds.  This  has  been  done  by  some  of  the  states,  and  data 
accompany  the  maps,  giving  the  number  of  inhabitants  in  every  house  and  the 
average  number  of  animals  kept  upon  every  farm.  These  surveys  and  maps 
enable  the  state  board  of  health  to  intelligently  use  the  typhoid  and  other 
reports  coming  in,  and,  through  their  local  agents,  protect  the  watershed  in- 
volved at  once  and  most  effectively.  It  even  goes  further  than  that.  These 
maps  enable  the  department  to  intelligently  judge  the  situation.  Suppose 
the  case  is  smallpox;  the  map  may  show  that  the  tenant  conducts  a  dairy  and 
at  once  his  route  is  gone  over  and  exposed  persons  vaccinated.  Or  it  may  be 
typhoid  fever;  and  proper  disinfectants  are  left  and  full  directions  given  for 
sterilizing  the  dejecta.  Also,  persons  living  along  the  streams  that  may  have 
already  been  contaminated  are  warned  to  boil  the  water  and  any  waterworks 
drawing  their  supply  from  that  shed  are  inspected  and  warned.  Thus,  a 
small  matter  in  an  isolated  locality  may  become  the  great  concern  of  the 
state.  To  physicians  it  may  be  said  that  their  duty  imperatively  demands 
that  they  promptly  report  all  infectious  diseases,  so  that  this  machinery 
may  be  set  in  motion. 

The  large  watersheds,  of  course,  involve  rivers,  and  they  flow  through 
all  kinds  of  country.  Mountain  regions  cause  little  contamination,  while 
valleys  and  plains  may  do  so  to  a  serious  degree. 

To  one  who  has  never  studied  such  problems  the  amount  of  literature 
and  reports  issued  about  the  Croton  watershed,  from  which  New  York  city 
is  supplied,  would,  if  he  saw  them  all,  be  a  revelation,  and  the  sums  of  money 
spent  would  stagger  him.  And  this  is  hut  one  of  the  important  watersheds. 
A  detailed  study  of  the  host  of  problems  involved  in  caring  for  an  important 
watershed  would  tire  my  readers,  and  we  will  leave  to  the  engineers  and  pro- 
fessional sanitarians  their  detailed  treatment. 

A  few  salient  features  demand  some  words.  River  water  is  usually  rich 
in  bacteria,  but  the  important  matter  is  to  keep  out  typhoid  bacilli,  the  com- 
mon colon  bacillus,  and  all  kinds  of  sewage.  Lakes  and  slow-flowing  streams 
are  natural  sedimentation  basins,  and  such  matters  as  coal,  culm,  sand,  clay, 
mica  particles,  and  mud  settle  out.  But  in  a  rapid-flowing  stream  they  do  not. 
One  of  the  sights  that  astonish  visitors  to  Harrisburg  is  seeing  the  coal 
fleet  at  work  pumping  coal  out  of  the  Susquehanna  River.  At  times  of 
freshet,  when  this  river  carries  twice  as  much  water  as  does  Niagara  Falls, 
millions  of  tons  of  coal  culm  is  carried  down  stream  from  the  distant  mines. 
At  every  eddy  or  swirl  of  the  water,  the  heavier  particles  of  coal  drop  to  the 
bottom  of  the  river  and  pile  up  in  heaps.  Then,  after  the  water  falls  from 
ten  to  twenty  feet,  this  coal  is  pumped  up  to  a  screen  and  carried  away  in 
flatboats.  A  few  years  ago,  before  the  city  installed  a  filter  plant,  the  finer 
particles  of  coal  made  the  water  so  foul  that  it  was  absolutely  undrinkable 
at  times,  and  it  is  no  exaggeration  to  say  that  laundry  work  had  to  go  un- 
done. To-day  the  filter  gives  sparkling  water  at  these  times  of  freshet. 
Now  that  was  our  local  question;  other  communities  have  theirs, —  and  the 
rivers  carry  nearly  every  abomination  ever  heard  of,  much  of  which  cannot 
be  successfully  filtered  out. 


130  HYGIENE 

It  is  a  big  problem  for  the  state  to  control  corporate  contamination  of 
waterways  because  it  is  an  equally  big  question  for  coal  and  mineral  mining 
companies  to  devise  ways  for  the  disposition  of  dirt,  waste,  and  tailings.  Iron 
works  use  immense  quantities  of  water  and  so  do  certain  refineries,  dye  houses, 
chemical  works,  pulp  and  paper  works,  strawboard  mills  and  hosts  of  other 
industries.  A  look  at  the  Schuylkill  River  at  Philadelphia  or  the  Chicago 
drainage  canal  makes  one  a  pessimist  about  river  water  supply.  Neverthe- 
less there  are  rivers  and  rivers.  Some  must  be  inevitably  contaminated,  and 
it  would  be  slow  suicide  to  use  them  for  a  municipal  supply.  Thus  far  the 
states  do  not  discriminate  between  streams  (on  paper),  but  they  must  do  so 
in  fact.  This  "  gets  on  the  nerves  "  of  rural  dwellers  and  small  towns.  The 
Susquehanna  River  must  be  used  for  a  water  supply,  and  the  cities  up  the 
state  do  not  see  why  they  should  be  required  to  install  sewage  disposal  plants 
to  keep  from  poisoning  Harrisburg  any  more  than  Harrisburg  can  see  why  she 
should  do  the  same  thing  to  keep  from  poisoning  the  towns  down  the  river, 
and  the  farmer  can't  see  why  his  hogpens  should  not  be  allowed  anywhere 
upon  the  banks  of  the  stream.  It  does  seem  hard  to  let  the  big  trust  ruin  a 
stream  and  fine  the  man  who  runs  a  one-inch  sewer  into  another  one,  and  it 
does  seem  hard  to  we  heavily  taxed  towns  to  build  bonded  disposal  plants 
that  do  not  do  us  one  particle  of  good.  It  seems  to  be  hard  for  us  and  good 
for  "  the  other  fellow,"  but  remember  the  chaps  up  stream.  As  a  matter  of 
fact,  legislatures  are  considering  the  question  of  the  state  building  or  helping 
to  build  these  disposal  plants  and  they  will  doubtless  consider  in  time  helping 
the  farmer  to  meet  his  obligations  to  public  hygiene.  It  is  not  right  to  expect 
a  three  thousand  dollar  farm  to  build  a  two  thousand  dollar  retaining  wall 
in  order  to  protect  a  watershed,  nor  can  municipalities  do  the  state's  work 
in  protecting  the  dwellers  of  the  rural  districts.  All  this  will  finally  devolve 
upon  the  state. 

There  are  certain  things  we  cannot  do  and  be  within  the  limit  of  safety. 
If  a  watershed  supports  a  population  of  over  one  hundred  per  square  kilo- 
meter, the  surface  water  is  so  liable  to  contamination  that  we  run  a  grave  risk, 
despite  all  care,  if  we  collect  and  use  that  water  without  adequate  and  well- 
supervised  filtration.  The  whole  subject  of  filtration  is  presented  in  another 
chapter.  If  the  agitation  for  reforesting  the  watersheds  results  in  anything 
practical,  a  long  step  will  have  been  taken  to  conserve,  not  only  the  forests, 
but  public  health  as  well.  Another  thing  we  cannot  do  is  to  prevent  the  dis- 
tribution of  fertilizers  over  watersheds.  Probably  there  is  little  danger  from 
commercial  fertilizers,  but  there  needs  to  be  some  supervision  of  barnyard 
manure  and  of  night  soil.  It  has  impressed  me,  but  it  is  not  definitely 
proven,  that  the  micro-organisms  in  manure  convert  the  organic  chemicals 
therein  into  inorganic  forms.  If  this  be  true,  there  is  but  little  danger  to  be 
apprehended  if  the  manure  is  allowed  to  stand  in  heaps  for  some  time  before 
being  spread  upon  the  land.  As  this  is  common  practice,  nothing  need  be 
done  beyond  what  is  already  the  rule. 

A  question  of  both  urban  and  rural  interest  is  that  of  self-purification  of 
streams.  Certainly  sedimentation  and  oxidation  both  combine  to  bring  this 
about.     The  first  process  is  favored  by  a  sluggish  current,  while  a  shallow 


SPECIAL  RURAL  HYGIENE 


131 


and  swiftly  flowing  stream  churns  up  the  water  and  aerates  it  effectively. 
Most  streams  have  reaches  of  both  kinds,  and  surely  do  much  toward  their 
own  cleansing.  Furthermore,  clay  and  aluminum  sulphate  in  the  water 
act  as  coagulants  and  precipitate  many  impurities,  while  algae,  infusoria,  and 
micro-organisms  convert  organic  matter  into  inorganic.  However,  the 
vitally  important  matter  of  killing  the  putrefactive  and  pathogenic  bacteria 
is  not  accomplished  by  these  natural  methods  or  is  but  imperfectly  accom- 
plished. 

Rural  water  supply  demands  extreme  care,  since  the  usual  supply  is 
from  a  very  limited  source  and  any  contamination  cannot  be  adequately 
diluted.  Organic  impurities  from  marshes  and  graveyards  are  to  be  sedu- 
lously avoided,  and  running  brooks  should  be  explored  throughout  their 
entire  length  and  extent  of  watershed  before  they  are  used  as  a  supply. 

Algae  or  diatoms,  especially  of  yolvox,  uroglena,  and  anabena,  develop  a 
disagreeable  odor  and  taste  in  water  infected  with  them,  but  they  are  not 
dangerous  to  health,  although  far  from  pleasant.  One  grain  of  copper  sul- 
phate to  fifty  gallons  of  water  will  effectually  kill  these  growths.  As  they 
grow  only  in  the  light,  covering  an  infected  spring  will  prevent  the  formation 
of  the  green  scum.  Eggs  of  parasites  such  as  round  worm  and  due  to  hog 
excrement,  the  ankylostoma  duodenale  and  the  organisms  of  amebic  dysen- 
tery may  all  be  found  in  a  rural  water  supply. 


A  Farm  Filter 

It  is  composed  of  a  water-tight  trough  divided  into  four  compartments.  The  one 
most  distant  from  the  barrel  is  half  filled  with  gravel,  powdered  charcoal,  and  clean 
sand,  as  shown;  the  second  one  is  left  empty;  the  third  one  is  two  thirds  filled  with 
gravel,  charcoal,  and  sand;  the  fourth  one  is  empty. 

The  heavy  marks  in  partitions  indicate  rows  of  half-inch  augur  holes  across  par- 
titions at  levels  marked. 

Il  is  a  good  filter  when  kept  clean  and  constantly  filled  to  capacity.  It  is  the  old 
Cutbush  filter  formerly  used  in  the  United  States  Navy. 

Domestic  filters  are  often  needed  on  the  farm,  and  there  are  several  types 
dealers  sell  in  the  smaller  cities.  The  trifling  little  strainers  amount  to  fittle, 
but  those  made  of  double  soft  earthenware  containers  and  the  stone  cylinder 


132  HYGIENE 

filters  are  effective  and  safe.  The  latter  type  cannot  be  used  without  plumb- 
ing connection  to  an  elevated  source  of  supply.  Domestic  filters  with  soft 
materials,  sand,  charcoal,  etc.,  are  hard  to  keep  clean  and  pure. 

Methods  other  than  filtration  may  be  used  to  purify  water.  Farmers 
understand  the  process  used  to  aerate  milk,  and  they  know  how  fully  it  may 
dispose  of  disagreeable  odor  and  taste.  The  same  thing  is  true  of  water. 
Pouring  water  repeatedly  through  a  wire  sieve  removes  hydrogen  sulphide 
and  other  gases  as  well  as  dissolved  organic  matters.  Boiling  water  kills 
most  fungi  and  bacteria,  lessens  organic  matter,  and  removes  most  carbo- 
nates, iron  salts,  and  sulphides. 

The  addition  of  about  six  grains  of  alum  to  the  gallon  of  water  will  co- 
agulate suspended  matter  and  precipitate  it.  The  alum  process  is  largely 
used  in  municipal  filtration  plants  and  the  amount  needed  is  determined 
daily.  In  domestic  use,  six  grains  per  gallon  is  merely  approximate,  but  is 
safe.  As  a  matter  of  fact,  if  the  water  is  boiled  first,  and  the  alum  added 
before  it  cools  down  very  much,  the  precipitation  is  hastened.  Do  not  add  to 
boiling  water.  If  water  is  boiled  and  the  alum  added  when  it  cools  down  to 
about  100  degrees  F.,  then  filtered  through  a  stone  or  earthernware  filter  and 
finally  aerated,  it  is  remarkable  how  much  it  is  improved. 

Ice  supply  and  ice  ponds. —  Researches  conducted  by  the  State  Board  of 
Health  of  Massachusetts  showed  that  there  were  eighty-one  per  cent  as  many 
bacteria  in  the  snow  ice  as  in  the  waters  from  which  it  formed;  ten  per  cent  as 
many  in  all  other  ice,  and  two  per  cent  as  many  in  the  clear  ice.  P.  Sacerdote 
has  proven  that  the  bacteria  abound  in  the  center  or  opaque  portion  of  masses 
of  ice,  while  the  outer  and  clear  portion  is  much  more  free  of  them.  W.^H. 
Park  found  no  bacilli  living  at  the  end  of  twenty-two  weeks  in  ice  frozen  from 
water  containing  before  freezing2,560,410t}phoid  bacilli  percubic  centimeter. 

All  this  goes  to  prove  that  recently  frozen  ice  may  be  as  dangerous  as  is 
the  waterway  or  pond  from  which  it  is  cut,  but  that  the  cutting  of  ice  long 
frozen  or  its  storage  for  a  few  months  before  it  reaches  the  consumer  mark- 
edly reduces  the  dangers. 

In  a  recent  report  of  the  Massachusetts  State  Board  of  Health  I  observe 
that  they  demand  a  careful  inspection  of  the  watersheds  of  ice  ponds,  and 
grant  permits  to  cut  ice  only  after  approval  in  specific  cases.  This  protects 
the  public.  They  commonly  exact  that  snow  ice  and  the  first  inch  of  clear 
ice  be  rejected. 

I  have  carefully  observed  the  harvesting  of  ice  in  the  northern  states,  and 
am  convinced  that  the  ice  there  is  not  only  safer,  from  its  long  refrigeration, 
but  is  more  scientifically  handled  and  housed  than  is  the  case  in  more  south- 
erly states,  where  the  supply  is  precarious  and  must  be  quickly  harvested. 
Artificial  ice  is  better  for  the  milder  regions.  Rural  dwellers  with  small  pri- 
vate ice  houses  will  do  well  to  apply  to  the  health  authorities  for  an  inspection 
before  cutting  ice  from  any  pond  or  stream  at  all  liable  to  contamination. 

Infected  wells  are  a  source  of  much  illness  in  rural  districts.  Artesian 
wells  pierce  geological  basins  and  their  water  is  pure,  but  most  so-called 
artesian  wells  are  actually  not  so  at  all.  In  many  districts  an  artesian  well 
is  a  geological  impossibility,  and  the  wells  known  as  artesian  are  merely  deep 


AN    IDEAL    RURAL    WATER    SUPPLY 

AN    UNCONTAMINATED    STREAM    SUPPLY 

A    FARM    SPRING    RUDELY    BUT    EFFECTIVELY    PROTECTED    FROM    CATTLE 


SPECIAL  RURAL  HYGIENE  133 

Wells,  and  some  of  these  deep  wells  are  most  impure.  A  false  sense  of  security 
is  often  engendered  by  the  lies  of  the  well  driller.  No  man  should  risk  the 
expenditure  of  several  hundred  dollars  in  sinking  a  deep  well  until  after  he 
has  had  expert  advice  as  to  geologic  and  sanitary  conditions.  Needless  to 
say,  sinking  wells  near  to  barnyards  or  vaults  is  dangerous.  Graveyards 
are  especially  liable  to  infect  deep  wells.  In  my  former  country  practice  I 
have  been  actually  discharged  for  daring  to  ascribe  typhoid  to  bad  wells 
infected  by  neighboring  cases,  and  some  of  these  same  people  drank  the  water 
despite  my  warning,  and  died  of  typhoid  fever.  Such  fatuous  conduct  is  a 
mystery  to  me,  but  I  know  it  is  common.  When  a  neighbor  of  mine  closed 
a  condemned  well  he  was  threatened  with  suit  b}-  several  aggrieved  users, 
simply  because  the  water  was  colder  than  the  city  supply  and  these  people 
wanted  to  save  the  cost  of  ice. 

The  following  is  from  the  Virginia  Health  Bulletin,  published  by  the 
Virginia  Department  of  Health: 

The  location  of  the  well  is  of  the  greatest  importance.  It  should  be  as  far  as 
possible  from  the  house,  barn,  and  privy.  If  possible  the  surface  of  the  ground  about 
the  well  should  be  a  lircle  higher  than  the  surrounding  soil,  so  that  any  surface  washings 
may  be  carried  away  from  the  top  of  the  well.  The  ground  about  the  top  should  be 
well  sodded  in  grass.  This  not  only  adds  to  the  attractiveness  of  the  well,  but  it  takes 
care  of  a  great  deal  of  water  that  would  otherwise  have  to  stand  in  pools  about  the 
well.  If  the  stock  have  i:o  be  watered  from  the  well  there  should  be  a  pipe  leading  to 
a  stock  trough  not  less  than  twenty  feet  away,  so  that  the  stock  need  no;  come  up  to  the 
well  itself. 

A  well  to  be  safe  should  be  not  less  than  twenty  feet  deep.  Thai:  is  to  say,  twenty 
feet  from  the  surface  of  the  ground  to  the  top  of  the  water.  It  should  go  well  through 
the  surface  soil,  preferably  through  a  layer  of  clay.  The  lining  should  be  of  brick  or 
stone  laid  in  cement.  Any  lining  that  allows  water  to  seep  through  i:  above  the 
surface  of  the  water  may  lead  to  infection.  The  space  between  the  casing  and  the 
surrounding  soil  should  be  filled  with  sand  or  earth. 

The  top  of  the  well  should  be  raised  from  the  ground  about  a  foot,  and  set  on  a 
cement  or  masonr}- coping  that  goes  at  least  three  feet  below  the  surface  of  the  ground. 
Over  the  top  should  be  laid  a  solid,  double  tongue  and  groove  flooring  tha.  is  absolutely 
waterproof.  This  is  essential.  Most  wells  are  polluted  by  material  that  falls  in  or  is 
washed  in  from  the  top,  and  not  by  seepage  through  the  soil. 

On  the  well  top  there  should  be  put  a  good  pump,  carefully  set  so  as  to  exclude 
leakage  from  around  its  base.  If  the  pump  cannot  be  used  there  should  be  an  auto- 
matic tipping  bucket.  The  well  bucket  should  not  be  handled  with  the  hands.  Many 
wells  have  been  infected  by  handling  the  bucket  with  soiled  hands  and  then  letting  it 
back  into  the  well,  the  filth  being  then  washed  off  into  the  well. 

Below  the  spout  there  should  be  a  trough  with  a  pipe  leading  some  distance  away 
so  that  the  waste  water  may  be  carried  away  from  the  well. 

A  well  constructed  in  the  manner  described  above  will  almost  always  furnish  a 
water  that  is  perfectly  safe,  and  the  saving  of  sickness  and  trouble  will  many  times  over- 
pay for  the  expense  and  care  involved. 

Springs. —  A  bubbling  spring  rising  out  of  clean  soil  is  an  almost  ideal 
supply,  but  even  such  a  spring  may  be  and  often  is  contaminated.  It  is 
always  well  to  wall  in  the  spring  with  stone  or  concrete  and  lay  sod  or  gravel 
around  it  upon  ground  graded  away  from  the  spring.     Algae  are  prevented  by 


134 


HYGIENE 


roofing  over  the  spring.  No  dirt  or  rubbish  should  be  allowed  to  remain  near 
by.  If  the  spring  is  on  a  sidehill,  it  is  well  to  terrace  above  it  or  build  a 
diverting  retaining  wall. 

1  Cisterns  are  a  poor  investment  in  a  city,  but  in  rural  districts  afford  soft 
water  for  the  laundry  work  and  sometimes  fair  water  for  culinary  purposes. 
Much  that  is  said  about  wells  applies  equally  to  cisterns.  No  masonry 
should  be  laid  with  lime  mortar,  cement  being  preferable.  It  is  well  to  taper 
the  bottom  so  the  cistern  can  be  readily  cleansed.  In  a  sandy  soil  it  is  almost 
impossible  to  build  any  but  a  tapering  one,  as  the  earth  falls  in  when  exca- 
vating. Use  good  cement  for  the  inside  dressing.  All  cisterns  should  be 
ventilated,  but  the  openings  should  be  covered  with  wire  mesh  to  exclude 
mosquitoes  and  flies.  If  one  keeps  pigeons  on  the  farm,  it  is  hard  to  prevent 
their  fouling  the  roof  supplying  the  cistern.  Spouting  should  be  carefully 
looked  after  and  all  accumulations  removed  at  regular  intervals.  A  sagging 
spout  may  hold  water  and  breed  mosquitoes  that  are  carried  down  to  the 
cistern  with  the  next  rain. 


Rider  and  Ericsson  Hot  Air  Pumping  Engines 

The  farmer  who  wants  a  pump  that  works  every  day  will  do  well  to  install  some 
type  of  hot  air  engine.  The  pump  can  be  made  suitable  for  any  situation,  and  the 
furnace  is  made  to  suit  various  kinds  of  fuel.  There  is  no  climbing  a  tower  with 
such  an  outfit  and  neither  will  it  blow  down,  like  a  tower,  nor  blow  up  like  a  gasolene 
engine. 

Hauled  water  loses  its  gases  and  is  made  more  palatable  for  drinking  if 
aerated.  Containers  had  best  be  regular  tank  wagons,  but  casks  with  good 
covers  and  well-charred  inside  do  very  well.  If  stored  in  barrels  they  should 
be  well  covered  and  be  frequently  cleaned,  and  when  emptv,  exposed  to  the 
sun  until  dry.     Do  not  use  denatured  alcohol  barrels. 

Tanks  a^id  piped  water. —  While  very  well  for  fire  protection,  water  in 
elevated  tanks  usually  tastes  very  flat.     The  common  wind  engine  or  wind 


SPECIAL  RURAL  HYGIENE  135 

mill  may  pump  a  sufficient  supply,  but  a  hydraulic  ram  or  a  small  gasoline 
or  hot-air  engine  is  not  dependent  upon  the  uncertain  factor  of  varying  winds 
or  lack  of  them.  If  a  hill  is  near  at  hand,  it  is  better  to  erect  a  concrete  or 
cement  tank  on  its  side  or  summit  and  deep  enough  in  the  earth  to  keep  the 
water  cool  in  summer.  A  protected  reservoir  like  that  is  less  apt  to  freeze  in 
winter  than  is  an  exposed  tank.  It  pays  any  modern  farm  to  build  and  main- 
tain a  really  good  system.  Piping  and  plumbing  generally  is  considered  in 
Chapter  XX,  and  the  same  principles  apply  on  the  farm  as  do  elsewhere.  It 
does  not  pay  to  install  poor  work  and  a  competent  plumber  should  be 
employed. 

Barnyard  drainage. —  It  is  hard  to  define  rules  for  the  entire  country. 
In  the  East  we  have  the  expensive  and  wasteful  "  bank  barn,"  and  stable 
manure  and  the  straw  stack  are  piled  in  the  barnyard.  In  the  West  there  is 
a  tendency  to  spend  less  money  in  barn  construction  and  to  erect  a  series  of 
smaller  buildings  each  for  its  own  purpose.  This  latter  is  the  better  plan. 
It  is  well  to  have  the  stock  housed  apart,  and  the  question  of  drainage  is  a 
simpler  one.  Manure  pits  are  not  only  more  sanitary  than  is  the  open  heap, 
but  they  cause  a  real  saving  of  valuable  fertilizing  material.  In  New  Jersey 
and  other  truck-raising  districts  the  stable  manure  is  so  disposed  that  the 
liquid  portion  is  caught  and  is  used  upon  certain  growing  vegetation.  By 
this  plan  there  is  no  barnyard  drainage  except  surface  water,  which  presents 
no  sanitary  problems.  In  the  bank  barnyard  the  soggy  dungheap  oozes  a 
trail  of  wasteful  abomination  most  of  the  time  and  always  so  after  a  rain. 
Nothing  but  condemnation  can  be  written  of  this  plan  and  it  contaminates 
thousands  of  small  streams. 

The  proper  way  to  provide  for  barnyard  drainage  is  to  have  none. 
Down  spouts  from  buildings  should  never  be  allowed  to  empty  near  to  the 
dungheap,  but  the  water  should  be  directed  away  from  the  building  and 
grounds.  It  takes  very  little  piping  to  do  this.  It  seems  very  strange  that 
while  an  Ohio  farmer  will  buy  miles  of  subsoil  drain  pipe,  most  of  our  Penn- 
sylvania farmers  cannot  be  induced  to  purchase  two  hundred  feet  of  terra- 
cotta sewer  pipe.  If  manure  heaps  are  covered  and  no  rain  water  allowed  to 
run  into  them,  little  liquid  drains  from  them,  especially  if  the  soiled  straw 
bedding  is  piled  up  with  the  manure.  It  is  well  to  run  a  drain  from  the  stalls 
to  carry  away  urine,  and  when  a  manure  pit  is  well  placed  the  urine  can  be 
run  into  it.  Where  trucking  is  done  it  will  pay  to  catch  the  drip  in  a  tank 
wagon  and  use  it  upon  certain  crops.  In  addition  to  this,  flies  are  one  of  the 
farm  nuisances,  and  it  is  well  known  that  they  breed  in  stable  manure.  If  the 
manure  is  kept  in  covered  pits  and  screened  at  the  openings,  the  generation  of 
flies  is  very  much  reduced.  Various  chemicals  have  been  used  upon  manure 
to  prevent  the  development  of  flies,  but  the  matter  is  hardly  worked  out  to  a 
satisfactory  basis  nor  the  influence  of  these  chemicals  upon  crops  sufficiently 
determined. 

Sewage. —  This  question,  as  it  relates  to  cities,  is  discussed  elsewhere, 
and  much  that  is  said  applies  to  the  farm  as  well.  It  is  certainly  desirable 
that  the  farm  be  possessed  of  a  water  supply  under  pressure.  When  so  sup- 
plied   the  plumbing  may  be  of  the  same  general  type  of  city  installation. 


136 


HYGIENE 


State  boards  of  health  generally  are  coming  to  the  conclusion  that  the  pollu- 
tion of  streams  by  sewage  must  cease,  and  this  will  apply  to  the  farmer  as  well 
as  to  the  city  dweller.  The  old  cesspool  is  an  abomination,  but  what  is  known 
as  a  "  sink  "  may  be  used  in  some  locations  where  rock  strata  allow  seepage 
into  harmless  areas  not  close  to  wells  or  residences.  In  a  sandy  soil  these 
sinks  should  be  prohibited  entirely.  Where  they  may  be  permitted  it  is  well 
to  excavate  to  some  depth  and  at  some  distance  from  the  house.  After  rock 
is  reached,  drill  into  it  as  far  as  the  hand  drill  will  go  and  load  the  hole  with 
two  or  three  sticks  of  dynamite  and  fill  in  over  it  dry  earth  to  the  top.  The 
explosion  of  deeply  placed  dynamite  rends  the  rock  strata  to  some  depth  and 
provides  drainage.  House  drainage  may  be  run  into  this  sink  through  piping 
protected  by  a  screen  to  keep  out  large  masses  that  might  obstruct  the  drain. 
This  plan  is  far  from  ideal,  but  may  be  used  in  the  absence  of  a  better  one. 
A  better  plan  is  to  pipe  the  sewage  to  a  settling  tank  which  connects  (a  few 
feet  above  its  bottom)  with  an  automatically  siphoned  flush  tank  discharging 
the  material  into  irrigating  gutters  placed  in  a  convenient  field.  By  this  plan 
the  sewage  is  macerated  and  discharged  at  intervals  upon  the  soil,  which 
quickly  absorbs  the  liquid.  In  summer  it  is  well  to  occasionally  fork  over  or 
spread  lime  upon  the  area  receiving  the  drainage.  The  plan  of  construction 
is  here  sketched.  (See,  also,  "Plumbing,"  in  Chapter  XX,  and  "Sewage  Dis- 
posal," in  Chapter  XXII.) 


Plan  for  Home  Drainage 

This  plan  shows  the  principle  but  not  the  details,  which  must  be  left  to  a 
plumber  who  is  intelligent  and  can  work  out  the  scheme  according  to  the  fall 
and  other  varying  conditions.  These  tanks  may  also  be  discharged  into  sub- 
surface irrigation  systems  laid  near  the  surface  with  open-jointed  drain  tiles. 
Garbage  on  the  farm  should  be  kept  in  covered  galvanized  iron  cans  and  either 
fed  to  the  hogs  daily  or  buried  in  the  earth  twice  a  week.  i    \    ^ 

Vaults. —  Some  method  for  the  disposition  of  human  excrement  is  neces- 
sary to  civilization,  but  the  farmer  usually  selects  the  worst  possible  method. 
Except  where  sewers  are  installed,  dry  ashes  or  dried  earth  should  always  be 


SPECIAL  RURAL  HYGIENE 


137 


mixed  with  the  dejecta.  Very  simple  appliances  are  required,  and  the  details 
vary  only  in  accordance  with  the  size  and  location  of  the  closet.  An  outside 
dry  closet  should  not  be  over  one  hundred  and  fifty  feet  from  the  house,  nor 
closer  than  one  hundred  feet.  Place  it  on  the  opposite  side  from  the  well  and 
see  that  it  is  comfortable  and  well  roofed.  Keep  a  divided  barrel  (one  sawed 
through  the  middle,  and  so  not  too  high  for  a  child  to  reach)  filled  with  dry 
earth  or  ashes  inside  and  provide  a  scoop  holding  a  pint,  to  apply  the  ashes. 
The  accompanying  pen  drawing  shows  how  an  outside  closet  should  not  be 
constructed  and  also  how  the  same  wretched  building  may  be  "  revised." 
The  box  receiver  figured  is  to  be  tightly  constructed  and  placed  some  little 
distance  above  the  ground.  It  should  be  frequently  hauled  away  and  a  few 
inches  of  earth  or  ashes  placed  in  it  before  it  is  replaced.  The  construction 
should  be  such  as  to  exclude  flies  as  far  as  is  possible,  wire  screening  being 
used  where  necessary.  In  the  summer  more  earth  should  be  used  than  is 
necessary  in  cold  weather.  The  attention  to  a  dry  closet  is  annoying  to  some 
persons,  but  the  advantages  far  outweigh  the  trouble  and  much  sickness  may 
be  prevented. 


T^^h^^U 


Revision 
Adapted  from  illustrations  in  the  typhoid  issue  of  the  Virginia  Health  Bulletin. 

Fertilizers. —  The  handling  of  barnyard  manure  has  been  discussed 
already,  but  it  remains  to  be  said  that  some  sanitarians  advecate  its  removal 
to  the  fields  whenever  a  wagon  load  accumulates  and  it  is  claimed  that  its 
nitrogen  content  is  saved  by  this  method.  The  contention  has  been  made 
that  commercial  fertilizers  may  contaminate  a  watershed,  but  no  tangible  data 
has  come  to  my  attention  confirming  this  view. 

Sick  and  dead  animals. —  Many  animals  become  sick  through  unhealthy 
surroundings.  Every  horse  should  have  fifteen  hundred  cubic  feet  of  air 
space,  good  ventilation  and  light  in  his  stall,  and  clean  surroundings.  Cattle 
are  peculiarly  liable  to  tuberculosis,  and  the  "  fresh  air  propaganda  "  should 
be  extended  to  them  as  well  as  to  mankind.  In  the  appendix  at  the  end 
of  this  volume  the  diseases  of  animals  communicable  to  man  are  duly  con- 


138  HYGIENE 

sidered.  The  burial  of  dead  animals  should  be  carefully  conducted,  espe- 
cially if  they  have  died  of  anthrax  or  other  virulent  disease.  Always  bury 
them  deeply  and  cover  the  carcass  with  lime.  Animals  sick  with  contagious 
disease  should  be  isolated  at  once  and  rigid  quarantine  maintained.  In  most 
of  the  states  there  are  proper  departments  to  look  after  these  problems  and 
cases  of  contagious  disease  among  animals  must  be  duly  reported  in  some 
states. 

Milk  supply  and  the  many  questions  involved. —  The  general  problem  of 
milk  supply  is  so  extensive  and  involves  so  much  that  we  will  here  limit  our 
discussion  to  the  hygiene  of  the  matter  and  especially  as  it  involves  the  farmer 
and  the  dairy.  Probably  the  best  brochure  upon  the  whole  question  is  a 
seven  hundred  and  fifty  page  bulletin  (No.  41),  issued  by  the  United  States 
Public  Health  and  Marine  Hospital  Service,  and  entitled  "Milk  and  its  Rela- 
tion to  the  Public  Health."  To  it  and  to  the  reports  of  the  various  state  health 
boards  (notably  New  Jersey  and  Massachusetts),  I  am  indebted  for  much  of 
the  data  herein. 

That  infected  milk  causes  much  illness  is  so  well  known  as  to  require  no 
discussion,  but  it  is  not  so  generally  understood  that  it  is  responsible  for  serious 
epidemics,  especially  marked  by  an  explosive  onset,  and  a  whole  milk  route 
may  be  involved.  Furthermore,  milk  long  kept  without  proper  refrigeration 
is  a  good  culture  medium  and  even  when  mixed  with  other  milk  will  pro- 
liferate pathogenic  bacilli  as  readily  as  will  warm  dough  generate  yeast  cells. 
Typhoid  fever,  scarlet  fever,  diphtheria,  tuberculosis,  anthrax,  and  other 
diseases  are  so  spread  and  an  immense  amount  of  literature  exists  giving 
details  of  epidemics  so  produced.* 

Sources  of  contamination  are  many  —  the  chronic  bacillus  carrier,  the 
milker  who  fails  to  wash  his  hands  or  does  not  clean  his  finger  nails,  milkers 
nursing  contagious  disease,  the  tuberculous  milker,  the  one  who  moistens  his 
hands  with  saliva,  or  who  wears  dirty  clothing;  filthy  cows  and  dirty  stables, 
stable  and  barnyard  dust;  milk  pails  not  properly  scalded,  or  from  infected 
surroundings  becoming  contaminated;  defective  water  supply;  non-sterilized 
milk  coolers;  cans  not  properly  scalded  and  aired;  infection  received  at  the 
distributing  dairy  from  opening  and  mixing  contents  of  cans,  tasting  the  milk 
with  a  spoon  carried  from  can  to  mouth  and  then  to  another  can;  careless 
bottling  and  at  the  creamery. 

According  to  the  law  of  averages,  about  one  person  in  every  three  hun- 
dred, in  each  year,  has  typhoid  fever  in  this  country,  dairymen  contracting 
their  quota.  This  being  true,  it  is  to  be  expected  that  twenty-five  cases  ol 
typhoid  per  year  will  occur  at  dairy  farms  supplying  a  city  the  size  of  Wash- 
ington, D.  C.     The  potential  danger  in  such  a  normal  situation  is  so  great 

*Let  me  refer  to  a  few  authorities: 

E.  Hart,  Trans.  Inter.  Med.  Cong.     Lond.,   1897,  1,  1167,  1229,  and  1292. 
V.  C.  Vaughan  in  several  Reports,  Mich.  St.  Bd.  of  Health. 
W.  H.  Powers,  Rep.  Local  Govt.  Board,  Lond.,     1885,  p.  73. 
J.  S.  Fulton,  Jour.  Hyg.,  Camb.,  1901,  1,  p.  422. 
Ninth  An.  Rep.,  Bd.  of  Health,  Montclair,  N.  J.,  1903. 
The  writings  of  Busey  and  Kober,  Dist.  of  Col.  Health  Of.  Rep.,  1895,  etc. 


SPECIAL  RURAL  HYGIENE  139 

that  no  amount  of  care  devoted  to  the  milk  supply  can  be  regarded  as  ex- 
cessive. 

We  know  that  bacteria  exist  in  all  milk,  but  it  is  important  to  keep  down 
the  bacterial  count  to  as  low  a  proportion  as  is  possible.  Lactic  acid  fer- 
mentation will  normally  occur,  and  when  the  vessels  are  so  full  that  air  is 
excluded  and  the  milk  is  warm,  butyric  acid  will  follow  the  lactic  acid.  Pu- 
trefactive fermentation  is  not  apt  to  occur,  except  in  alkaline  milk,  and  such 
milk  as  well  as  the  ropy,  slimy,  soapy,  and  bitter  milks  must  be  destroyed  at 
once  and  the  containers  thoroughly  scalded  or  even  boiled.  If  milking  is 
done  in  a  cleanly  manner,  kept  clean  and  promptly  cooled,  and  then  kept 
cool,  there  is  little  proliferation  of  bacteria  except  by  over-long  keeping. 

Prevention  is  all  important.  All  herds  should  be  regularly  inspected 
by  a  state  veterinarian  or  one  appointed  locally.  It  is  especially  necessary  to 
exclude  tuberculosis.  The  state  of  New  Jersey  has  a  very  good  general  law 
upon  the  subject,  very  wisely  leaving  the  details  largely  to  the  officials.  The 
statute  is  here  reproduced. 

(Approved  May  16,  1893  —  Gen.  Stat.,  p.  53.) 

1.  That  the  local  board  of  health  of  any  city  of  this  state  shall  by  ordinance 
require,  from  time  to  time,  a  registry  of  all  cattle  kept  within  the  limits  of  said  city, 
which  registry  shall  state  the  place  of  keeping,  the  number  in  each  case  kept,  and  the 
number  of  these  intended,  or  used,  as  milch  cows;  and  it  shall  be  the  duty  of  the  owner 
of  any  such  cattle  to  make  registry  thereof  at  the  time,  place,  and  in  the  manner  that 
the  board  of  health  of  said  city  may  direct,  under  a  penalty  not  exceeding  fifty  dollars 
for  any  neglect  of  the  same;  provided,  that  no  such  registry  shall  be  made  by  any  board 
of  health  until  after  the  examination  of  the  stables  and  place  in  which  said  cattle  are 
kept,  and  until  it  is  known  to  the  satisfaction  of  said  board  rhat  they  are  in  good  sani- 
tary condition. 

2.  That  whenever  any  local  board  of  health  of  any  city  shall  have  reason  to 
suspect  the  existence  of  any  contagious  disease  among  cattle,  or  such  as  may  be  a  risk 
or  danger  to  the  food  or  milk  supply,  or  whenever  they  may  deem  it  necessary,  in  order 
to  prevent  the  occurrence  of  such  risk  or  danger,  they  shall  order  the  inspection  of  all 
cattle  that  are  kept  or  intended  for  meat  or  milk  production,  by  a  competent  veteri- 
narian chosen  by  them,  and  may  for  such  inspection  require  so  much  payment  for  such 
service  as  may  be  necessary  for  the  expenses  attending  such  inspection;  it  being,  how- 
ever, provided,  that  in  no  case  shall  the  amount  charged  exceed  fifty  cents  a  head  per 
year  for  dairies  often  cows  or  under,  and  for  all  dairies  above  ten  cows,  twenty-five 
cents  per  head  per  year;  provided  further,  that  no  charge  shall  be  made  against  any  one 
keeping  a  single  cow  for  family  use. 

3.  That  whenever  any  local  board  of  health,  or  any  veterinary  inspector  appointed 
by  said  board  shall  find  or  suspect  any  disease  in  any  cow,  or  in  any  herd  of  milk-pro- 
ducing cattle,  which  may  prove  harmful  to  the  meat  or  milk  supply,  the  state  board  of 
health  and  the  state  dairy  commissioner  shall  be  notified,  and  it  shall  be  the  duty  of  the 
dairy  commissioner  to  investigate  the  same,  and  he  shall  prohibit  the  sale  or  use  of  the 
milk  from  any  such  milch  cow,  but  he,  or  the  owner  of  said  milch  cow,  mav  ask,  through 
the  state  board  of  health,  a  report  from  some  veterinarian  appointed  by  the  state  board 
of  health  as  to  whether,  or  how  long,  it  will  be  necessary  to  continue  the  prohibition  of 
the  use  of  said  milk,  and  the  dairy  commissioner  or  the  state  board  of  health  may  pro- 
hibit the  use  of  said  milk  or  of  meat  of  any  animal  declared  by  a  veterinarian  of  the 
state  board  to  be  unfit  for  use. 


140  HYGIENE 

In  addition  to  this,  the  state  board  prohibits  the  transportation  or  sale 
of  milk  from  rural  districts  whenever,  in  the  opinion  of  the  authorities,  any 
danger  exists. 

Under  watersheds,  sufficient  was  said  about  the  water  supply,  but  dairy 
farms  should  especially  heed  the  warnings  and  should  supply  a  full  amount 
of  running  water.  It  is  impossible  to  keep  large  amounts  of  milk  clean  by 
water  carried  to  the  dairy  in  buckets. 

Cow  stables  must  be  built  in  such  manner  that  they  are  dry  and  well 
lighted.  Ceilings  and  side  walls  should  be  smooth  and  dust  tight,  and  never 
less  than  six  hundred  to  eight  hundred  cubic  feet  of  air  space  should  be 
allowed  for  each  cow.  Horses  should  have  even  more  than  that.  The  floors 
must  be  graded  to  carry  off  water  and  urine,  and  the  manure  should  be  re- 
moved every  day.  Every  cow  stable  should  be  provided  with  a  suitable 
place  for  washing  the  hands  and  for  putting  on  suitable  garments  for  milking. 
Cows  should  be  kept  clean  by  being  curried  or  brushed  every  day  and 
they  should  have  exercise  in  clean  places  and  a  dry  and  dust-free  bedded 
stall  at  night.  The  hair  on  the  flanks,  tail,  and  udder  should  be  clipped  at 
intervals.  Before  each  milking  the  udder  and  teats  should  be  washed  with 
tepid  water  and  the  parts  dried. 

Milk  is  handled  in  so  many  ways  that  the  only  safety  is  absolute  cleanli- 
ness clear  through  the  process,  and  the  exclusion  of  flies,  poultry,  and  sick 
people.  It  is  imperative  to  keep  the  milk  cool  and  to  avoid  dust  and  vessels 
having  wide  openings  exposed  to  the  air.  Some  of  the  milking  machines  are 
to  be  commended. 

From  a  comparison  of  statistics  available  I  find  that  approximately 
three  times  as  many  bottle-fed  babies  die  the  first  year  of  life  as  do  breast- 
nursed  children.  The  crime  of  the  American  unwilling  or  selfish  mother 
cries  to  high  heaven  for  vengeance.  A  bottle-fed  babe  consumes  about  five 
hundred  quarts  of  milk  during  its  first  year  and,  despite  all  possible  care,  cow's 
milk  is  not  a  suitable  diet  for  such  young  children,  nor  can  it  be  made  so.  It 
requires  unremitting  care  upon  the  part  of  the  dairyman  to  market  milk  that 
is  not  absolutely  dangerous  for  young  children.  As  a  physician  who  has  seen 
many  promising  babes  perish  from  their  mothers  being  so  fatuous  (to  use  too 
mild  a  term)  as  to  refuse  a  well-functionating  breast,  I  honestly  believe  the 
authorities  should  make  provision  for  two  kinds  of  milk.  The  first  kind 
should  be  safe  and  clean  and  suitable  for  adults;  the  second  kind  should  be 
produced  by  ideal  herds  under  ideal  conditions,  and  it  should  be  sold  at  double 
the  ordinary  price.  No  parent,  where  such  milk  is  procurable,  should  be 
allowed  to  feed  any  other  to  a  babe  under  two  years  of  age.  If  foolish  par- 
ents (and  the  father  is  often  to  blame)  insist  upon  the  bottle,  they  deserve  to 
pay  the  difference  in  price.  Poor  people  would  not  pay  the  difference  and 
the  result  would  be  a  far  larger  proportion  of  breast-fed  children.  I  know 
very  well,  from  actual  experience,  what  a  proposition  the  dairy  is  facing  to- 
day in  trying  to  aid  mothers  in  doing  what  nature  never  intended  should  be 
done,  and  I  also  know  that  to  keep  all  the  milk  up  to  the  proper  standard  for 
bottle-fed  babes  is  so  expensive  that  there  is  no  profit  in  the  dairy  business  at 
the  prices  adults  like  to  pay  for  milk,    I  also  know  that  three  fourths  of  city 


IDEAL    DAIRY    CONDITIONS    AT    BURNSIDE,    ECCLESTON,    MD. 
S.    M.    SHOEMAKER,    PROPRIETOR 


SPECIAL  RURAL  HYGIENE  141 

mothers  who  declare  they  cannot  nurse  their  babes  are  not  telling  the  exact 
truth.  It  is  a  matter  of  style  largely.  In  Norway  nearly  all  mothers  nurse 
their  babes.     In  Wurtemberg  nearly  all  mothers  refuse  the  breast. 

Chemical  standards  for  the  control  of  the  sale  of  milk  are  becoming  com- 
mon. I  figured  out  an  average  of  requirement,  based  upon  the  laws  of  thirty- 
three  states,  and  find  —  for  milk,  the  requirements  average  12.1  per  cent  total 
solids;  8.77  per  cent  solids  not  fat;  3.12  per  cent  fat.  The  rather  arbitrary 
determination  of  these  standards  is  shown  by  the  fact  that  subtracting  the 
second  figure  from  the  first  one  gives  3.23  per  cent  instead  of  3.12  per  cent. 
This  comes  from  eliminating  fractions.  Possibly  it  is  close  enough  for  prac- 
tical purposes.  There  is  a  movement  on  foot  to  set  aside  these  state  standards 
and  substitute  those  of  the  federal  government,  which  require  3.25  percent 
fat  and  8.5  per  cent  solids  not  fat.  From  some  considerable  experience  in 
estimating  the  amount  of  butter  fat  in  milk,  I  can  say  that  I  have  found  less 
than  3  per  cent  of  fat  in  whole  milk  from  a  mixed  stall-fed  herd  in  February 
and  March,  and  I  know  the  milk  was  not  diluted.  It  impresses  me  that  the 
requirements  should  be  more  flexible,  taking  into  account  the  season  of  the 
year.  I  have  seen  men  fined  in  court  for  selling  milk  below  the  state  standard 
in  February,  and  had  every  reason  to  believe  that  they  sold  milk  just  as  re- 
ceived from  the  cow.  We  should  have  standards,  but  there  is  so  much  varia- 
tion in  milk  that  a  mere  deficiency  of  a  point  or  two  in  butter  fat  should  not 
subject  one  to  a  fine  in  the  absence  of  other  factors  tending  to  prove  adultera- 
tion or  dilution.  As  regards  adulteration  with  chalk,  calves'  brains,  etc., 
that  sort  of  thing  is  largely  of  the  past.     Dilution  is  quite  common. 

There  is  absolutely  no  excuse  for  adding  preservatives  to  milk  commonly 
offered  for  sale.  Campers  and  those  traveling  may  find  occasion  to  do  so. 
It  is  illegal  to  sell  milk  containing  these  substances  in  many  of  the  states. 
Borax,  boric  acid,  benzoic  acid,  and  sodium  bicarbonate  have  been  used,  but 
formaldehyde,  under  fanciful  names  such  as  "  Freezine,"  is  more  commonly 
employed.     Such  practices  are  absolutely  bad. 

"  Certified  milk  "  was  originated  by  the  Fairfield  Dairy  Co.  and  the 
plan  has  been  copied  by  about  thirty  commissions  over  the  country  aiming  to 
market  milk  for  clinical  purposes  and  for  the  feeding  of  infants.  The  detailed 
plans  and  requirements  of  these  commissions  are  most  elaborate  and  are  given 
in  a  paper  by  Dr.  John  W.  Kerr,  of  the  Public  Health  and  Marine  Hospital 
Service,  and  published  by  the  service.  It  is  aimed  to  accomplish  the 
following : 

First.  An  absence  of  large  numbers  of  micro-organisms  and  the  entire  freedom 
of  the  milk  from  pathogenic  varieties. 

Second.  Unvarying  resistance  to  early  fermentative  changes  in  the  milk,  so  that 
it  may  be  kept  under  ordinary  conditions  without  extraordinary  care. 

Third.  A  constant  nutritive  value  of  known  chemical  composition  and  a  uniform 
relation  between  the  percentage  constituents  of  fat,  proteid,  and  carbohydrate. 

Legal  contracts  are  entered  into  by  the  commissions  and  the  dairymen, 
and  ideal  conditions  are  enforced.  The  proposed  legal  recognition  of  "  cer- 
tified milk  "  would  bring  about  the  plan  I  suggested  of  selling  two  grades  of 


142  HYGIENE 

milk.  The  question  of  infant  feeding  is  of  great  importance,  but  need  not  be 
discussed  here;  nor  is  it  necessary  to  say  much  about  pasteurizing  milk. 
Suffice  it  to  say  that  such  milk  prepared  for  infants  should  be  used  within 
twenty-four  hours.  The  process  is  highly  useful  in  the  preparation  of  cream 
for  butter-making.  However,  pasteurizing  milk  will  not  improve  its  char- 
acter one  particle  when  it  is  defective  or  deteriorated,  and  should  be  applied 
only  to  fresh  and  good  milk.  By  reason  of  the  fact  that  pasteurization  kills 
the  non-sporulating  lactic  acid  bacilli  in  milk,  such  milk  does  not  sour,  but 
putrefies  and  becomes  utterly  unfit  for  use. 

The  consumer  has  his  responsibilities  as  well  as  the  dairy.  Refrigera- 
tors and  milk  vessels  must  be  kept  clean.  Milk  had  better  be  kept  in  the 
bottles  in  which  it  comes.  Placing  coins  and  milk  tickets  in  pitchers  is  very 
apt  to  infect  the  milk.  -A 

Cheese,  meat,  and  milk  ptomaines. —  I  was  working  under  Vaughan  when 
he  discovered  tyrotoxicon,  one  of  the  milk  and  cheese  ptomaines.  In  his 
laboratory  the  chemical  data  worked  out  was  most  interesting,  but  need  not 
be  considered  here.  As  a  sanitary  matter,  these  ptomaines  are  produced  in 
milk  and  milk  products  kept  or  worked  in  filthy  surroundings.  Theoretically, 
they  may  be  generated  from  very  slight  infections,  but  practically  they  are 
seld  om  found  except  when  the  milk,  cheese,  or  ice  cream  is  very  badly  handled. 
Good  milk  may  produce  ptomaines  when  the  consumer  stores  it  in  a  filthy 
ice  box.  From  the  standpoint  of  sanitation,  the  danger  from  ptomaines  is  a 
threatened  penalty  for  carelessness  or  filthiness.  In  the  book,  "  Ptomaines 
and  Leucomaines,"  by  Vaughan  and  Novy,  the  points  are  made  that  milk 
should  be  aerated  and  chilled  promptly  after  milking,  and  they  instance  many 
cases  of  poisoning  by  tyrotoxicon  in  which  one  single  defect  or  a  few  very 
slight  ones  produced  the  conditions  favoring  the  generation  of  ferments. 
Very  unfortunately,  some  milk  or  milk  products  may  taste  and  smell  normal  in 
every  essential  particular,  and  yet  give  rise  to  dangerous  poisoning.  Mussels 
and  shellfish,  sausages,  cured  meats,  canned  foods,  and  especially  canned 
fish  and  meats,  and  some  "  fresh  "  meats,  and  especially  liver,  may  all  de- 
velop ptomaines.  When  traced  up,  these  foods  show  putrefactive  changes. 
I  nearly  lost  my  life  from  eating  liver  one  very  hot  day.  It  was  kept  over  for 
two  days  and,  while  nothing  abnormal  was  noted  at  first,  it  soon  developed 
a  frightful  odor. 

Butter  and  butter  substitutes. —  From  the  sanitar}^  standpoint,  butter 
should  be  good  if  the  rules  defined  under  milk  and  those  to  be  given  under 
creameries  are  fully  observed.  The  process  of  churning  and  the  working  of 
butter  present  practical  difficulties  making  the  production  of  a  uniform  butter 
somewhat  difficult,  but  a  clean  butter  is  seldom  unwholesome,  even  though 
the  flavor  leaves  something  to  be  desired.  Garlic  and  other  plants  may  taint 
butter  and  too  much  coloring  may  be  undesirable,  but  carrots,  annetto,  and 
turmeric  may  be  safely  used.  More  or  less  objectionable  butter  color  has 
been  used  by  some  makers.  There  is  a  great  outcry  against  oleomargarine 
and  butterine,  and  there  is  evidence  that  much  of  these  products  have,  in 
the  past,  been  made  of  bad  materials.  So  far  as  I  can  judge,  the  objections 
to  these  products,  when  made  of  good  materials,  are  not  very  valid  so  far  as 


SPECIAL  RURAL  HYGIENE  143 

hygiene  is  concerned.     Certainly  there  aie  many  persons  who  consider  good 
oleomargarine  a  tasteful  and  nutiitious  food. 

Creameries. —  The  general  rules  applying  to  milk  are  equall)  valid  as 
applied  to  creameries.  The  State  Board  of  Health  of  New  Jersey  enforces 
such  excellent  rules  that  they  are  here  reproduced  as  a  model  worthy  of  gen- 
eral application: 

RULES    GOVERNING   THE    CONSTRUCTION   AND   OPERATION   OF 

CREAMERIES 

1.  The  site  of  the  creamery  building  must  be  dry,  and  the  surroundings  free  from 
all  refuse  accumulations.  Creamery  buildings  must  not  be  located  near  any  stable, 
chicken  yard,  hog  pen,  or  slaughter  house,  and  no  open  privy  vault  or  other  receptacle 
for  filth  allowed  near  said  buildings.  If  cesspools  are  necessary,  they  must  be  screened 
to  prevent  the  entrance  and  exit  of  flies.  Waste  fluids  from  creamery  premises  must  be 
conducted  through  subsurface  drains  and  finally  disposed  of  in  a  manner  which  will 
not  create  a  nuisance. 

2.  If  the  creamery  is  provided  with  a  cellar,  this  apartment  must  be  well  lighted 
and  ventilated,  and  kept  scrupulously  clean  and  dry. 

3.  The  floors  of  all  rooms  in  which  milk  is  handled  must  be  covered  with  asphalt 
or  other  mater'al  impervious  to  water,  and  the  surfaces  graded  to  permit  qu  ck  escape 
of  waste  fluids  into  a  properly  constructed  drain. 

4.  No  room  in  any  creamery  which  is  used  for  receiving,  handling,  or  bottling 
milk  shall  be  used  for  any  other  purpose. 

5.  All  creamery  rooms  in  which  milk  is  stored,  handled,  or  exposed  must  be 
screened  to  prevent  the  entrance  of  insects. 

6.  All  vats  must  be  provided  with  removable  covers  of  a  pattern  approved  by  the 
state  board  of  healch,  and  all  vats  must  be  kept  covered  when  milk  is  contained  in  them. 

7.  The  milk  should,  when  practicable,  be  elevated  when  it  is  received  and 
before  it  is  transferred  from  the  dairymen's  cans  to  receptacles  provided  by  the  cream- 
ery, to  a  sufficient  height  to  permit  it  to  flow  by  gravity  through  open  channels  to  the 
separator,  cooling  apparatus,  cans,  bottles,  etc.  If  pumps  and  closed  pipes  are  used 
in  conveying  milk,  they  must  be  so  constructed  that  every  portion  of  their  interior 
surfaces  will  be  accessible  for  cleaning.  All  pipes  used  for  this  purpose  must  have  an 
internal  diamxeter  of  at  least  two  inches,  and  must  be  made  up  of  short  lengths.  All 
pipes,  separators,  coolers,  and  other  machinery  used  for  handling  milk  must  be  taken 
apart  daily,  and  all  surfaces  which  come  in  contact  with  milk  must  be  thoroughly 
cleaned  and  sterilized. 

8.  Every  creamery  should  be  equipped  with  a  steam  sterilizing  chamber,  large 
enough  to  receive  all  cans,  bottles,  and  utensils  used  in  handling  milk,  and  all  such  con- 
tainers and  utensils,  after  thorough  washing,  should  be  exposed  to  live  steam  at  a  tem- 
perature of  240°  F.  for  not  less  than  thirty  minutes  before  use. 

9.  No  measuring  rod  or  other  instrument  should  be  put  into  milk  unless  such 
rod  or  instrument  has  been  sterilized  before  use. 

10.  The  water  used  in  creameries  must  be  pure,  wholesome,  and  abundant  in 
quantity. 

11.  Every  portion  of  the  creamery  building  and  premises  must  be  kept  clean 
and  free  from  dust,  cobwebs,  and  accumulations. 

12.  Creamery  employees  must  be  cleanly  in  their  habits;  their  outside  garments 
should  be  white  and  clean,  and  warm  water,  soap,  and  clean  towels  must  be  provided 
to  permit  convenient  washing  of  their  hands. 


144  HYGIENE 

13.  The  temperature  of  milk  intended  for  sale  or  shipment  must  not  be  above 
50°  F. 

14.  All  milk,  at  the  time  it  is  received  at  the  creamery,  should  be  at  or  below^  a 
temperature  of  60°F. 

15.  Cats,  dogs,  fowls,  or  other  domestic  animals  must  not  be  kept  or  allovi^ed  in 
or  about  creamery  buildings. 

16.  Each  creamery  owner  or  manager  must  send  to  the  chief  of  the  division 
of  creameries  and  dairies,  when  requested  so  to  do,  a  statement,  giving  the  name  and 
address  of  every  person  supplying  milk  to  said  creamery,  the  quantity  of  milk  sent  by 
each  person,  the  amount  of  milk  shipped  or  delivered  from  the  creamery,  the  names 
and  addresses  of  the  persons  to  whom  such  milk  is  shipped  or  delivered,  and  such  other 
matter  relating  to  the  management  and  operation  of  such  creamery  as  may  be  requested 
by  said  chief  of  the  division  of  creameries  and  dairies. 

17.  Each  creamery  owner  or  manager  must  report  immediately  by  telegraph 
to  the  state  board  of  health,  Trenton,  N.  J.,  any  case  or  suspected  case  of  typhoid  fever, 
scarlet  fever,  diphtheria,  or  tuberculosis  occurring  amongthe  employees  of  the  creamery 
or  their  families,  or  among  the  persons  supplying  milk  to  the  creamery  or  their  families. 
The  manager  of  the  creamery  must  at  all  times  make  diligent  effort,  by  inquiry  or 
otherwise,  to  ascertain  whether  or  not  any  case  or  suspected  case  of  any  of  the  above- 
mentioned  diseases  exists  among  any  of  the  aforesaid  persons.  Failure  to  obey  this 
rule  will  result  in  the  immediate  revocation  of  the  license  issued  to  that  creamery. 

18.  No  person  suffering  with  typhoid  fever,  scarlet  fever,  diphtheria,  or  tubercu- 
losis shall  be  employed  in  or  permitted  to  enter  any  creamery  in  this  state. 

Score  cards. —  During  the  last  five  years  a  large  number  of  inspections  of  dairy 
and  creamery  premises  have  been  made  by  the  state  board  of  health  for  the  purpose 
of  ascertaining  the  conditions  existing  on  such  premises  and  securing  improvement  in 
them.  A  satisfactory  method  of  recording  the  results  of  such  investigations  and  of 
comparing  the  conditions  of  different  premises  has  been  found  to  be  one  involving  the 
use  of  score  cards  The  cards  at  present  in  use  in  this  state  for  scoring  dairies  and 
creameries  are  substantially  the  same  as  those  adopted  by  the  department  of  health  of 
the  city  of  New  York.  These  forms  are  given  below.  These  particular  form  have 
been  adopted  because  a  large  proportion  of  the  milk  produced  in  this  state  goes  to  the 
New  York  market,  and  it  was  therefore  believed  that  the  advantage  accruing  from 
uniformity  in  the  records  of  this  board  and  those  of  the  New  York  Health  Department 
would  more  than  ou  weigh  certain  disadvantages  which  these  forms  possess. 

No Score  allowed per  cent 

BOARD  OF  HEALTH  OF  THE  STATE  OF  NEW  JERSEY 

Dairy  Inspection  Division  of  Creameries  and  Dairies 

1  Inspection    No Time a.m.,     p.m.  Date 190 

2  Tenant P.  O.  Address 

3  Township County 

4  Owner Party  Interviewed 

5  Milk  retailed  at By  whom 

6  Address Since 

7  Is  shipped,  to  whom Address 

8  Distance  of  farm  from  creamery Occupied  farm  since 

9  No  of  cows Breed No.  Milking 

Quarts  milk  produced 


SPECIAL  RURAL  HYGIENE  145 

10  All  persons  in  the  households  of  those  engaged  in  producing  or  handling  milk 

are free  from  all  infectious  disease 

1 1  Date  and  nature  of  last  case  on  farm 

12  A  sample  of  the  water-supply  on  this  farm  numbered taken  for 

analysis 190 ....  and  found  to  be 

13  Size  of  cow  barn,  length.  .  .  .feet.     Width feet.     Height  of  ceiling 

STABLE 

Perfect  Allow 

14  Cow  stable  is located  on  eleva'ed  ground  wiih 

no  stagnant  water,  hogpen,  or  privy  within  100  fee 1        

15  Floors  are constructed   of  concrete  or  some  non- 

absorbent  material 1       

16  Floors  are properly  graded  and  water-tight 2        

17  Drops  are constructed  of  concrete,  stone,  or  some 

non-absorbent  material 2        

18  Drops  are water-tight    2        

19  Feeding  troughs,  platforms,  or  cribs  are well  lighted  and 

clean 1        

20  Ceiling  is  constructed  of and  is tight  and 

dust-proof  2       

21  Ceiling  is free  from  hanging  straw,  dirt,  or  cobwebs .  .        1        

22  Number     of    windows total     square     feet which 

is sufficient 2        

23  Window  panes  are washed  and  kept  clean 1        

24  Ventilation  consists  of 

which  is  sufficient  3,  fair  1,  insufficient  0.  ...       3        

25  Air  space  is cubic  feet  per  cow  which  is sufficient 

(600  and   over  —  3)     (500  to   600  —  2)     (400  to   500  —  1) 

(under  400  —  0) 3        

26  Interior  of  stable   painted   or  whitewashed   on which   is 

satisfactory  2,  fair  1,  never  0 2        

27  Walls  and  ledges  are free  from  dirt,  dust,  manure,  or  cob- 

webs          2        

28  Floors  and  premises  are free  from  dirt,  rubbish,  or  decayed 

animal  or  vegetable  matter 1        

29  Cowbeds  are clean 1        

30  Live  stock,  other  than  cows,  are excluded  from 

rooms  in  which  milch  cows  are  kept 2  

31  There  is direct  opening  from  barn  into  silo  or  grain  pit ...  .  1  

32  Bedding  used  is clean,  dry,  and  absorbent 1  

33  Separate  building  is provided  for  cows  when  sick 1  

34  Separate  quarters  are provided  for  cows  when  calving.  ...  1  

35  Manure  is removed  daily  to  at  least  200  feet  from  the 

bam  ( ft.) 2 

id     Manure  pile  is ....  so  located  that  the  cows  cannot  get  at  it 1        

37  Liquid  matter  is absorbed  and  removed  daily  and 

allowed  to  overflow  and  saturate  ground  under  or  around  cow 

barn 2        

38  Running  water  supply  for  washing  stables  is located 

within  building 1        

39  Dairy  rules  of  the  Department  of  Health  are ....  posted 1       


146  HYGIENE 

COW  YARD 

Perfect  Allow 

40  Cowyard  is properly  graded  and  drained 1        

41  Cowyard  is clean,  dry,  and  free  from  manure 2       


COWS 

42  Cows  have been  examined  by  Veterinarian 

Dale 190 .  .     Report  was 3 

43  Cows  have been  tested  by  tubercuHn,  and  all  tuberculous 

cows  removed 5 

44  Cows  are all  in  good  flesh  and  condition  at  time  of  in- 

spection          2 

45  Cows  are all  free  from  clinging  manure  and  dirt.     (No. 

dirty )    4 

46  Long  hairs  are kept  short  on  belly,  flanks,  udder,  and 

tail    1 

47  Udder    and   teats   of  cows    are.  .  .  .thoroughly   cleaned    before 

milking 2 

48  All  feed  is of  good  quality  and  all  grain  and  coarse  fodders 

are free  from  dirt  and  mould 1 

49  Distillery  waste  or  any  substance  in  a  state  of  fermentation  or 

putrefaction  is fed 1 

50  Water  supply  for  cows  is ... .  unpolluted  and  plentiful 2 


MILKERS  AND  MILKING 

51  Attendants  are in  good  physical  condition 1 

52  Special  milking  suits  are used 1 

53  Clothing  of  milkers  is clean 1 

54  Hands  of  milkers  are washed  clean  before  milking 1 

55  Milking  is done  with  dry  hands 2 

56  Fore  milk  or  first  few  streams  from  each  teat  is 

discarded 2 

57  Milk  is  strained  at and in  clean  atmosphere 1 

58  Milk  strainer  is clean 1 

59  Milk  is cooled  to  below  50°F.  within  two  hours  after  milk- 

ing and  kept  below  SO°F.  until  delivered  to  the  creamery 

60  Milk  from  cows  within  15  days  before  or  5  days  after  parturition 

is discarded 1 


UTENSILS 

61  Milk  pails  have all  seams  soldered  flush 1 

62  Milk  pails  are of  the  small  mouth  design,  top  opening  not 

exceeding  8  inches  in  diameter.     Diameter 2 

63  Milk  pails  are rinsed  with  cold  water  immediately  aftei 

using  and  washed  clean  with  hot  water  and  washing  solution .  .        2 

64  Drying  racks  are provided  to  expose  milk  pails  to  the  sun.  .        1 


SPECIAL  RURAL  HYGIENE  147 

MILK  HOUSE 

Perfect  Allow 

65  Milk  house  is located  on  elevated  ground  with  no  hogpen, 

manure  pile,  or  privy  within  100  feet 1  

66  Milk  house  has direct  communication  with.  ..  .building.  .  .  1  

67  Milk  house  has sufficient  light  and  ventilation 1  

68  Floor  is.  .  .  .properly  graded  and  water-tight 1  

69  Milk  house  is.  .  .  .free  from  dirt,  rubbish,  and  all  material  not 

used  in  the  handling  and  storage  of  milk 1        

70  Milk  house   has running  or  still   supply  of  pure,   clean 

water 1        

71  Ice  is used  for  cooling  milk  and  is  cut  from 1        

WATER 

72  Water  supply  for  utensils   is  from   a located 

feet  deep  and  apparently  is pure,  wholesome 

and  uncontaminated    5        

73  Is protected  against  flood  or  surface  drainage 2       

74  There  is privy  or  cesspool  within  250  feet  ( feci;) 

of  source  of  water  supply 2        

75  There       is stable,   barnyard,  or  pile  of  manure  or  other 

source    of   contamination    within    200    feet    ( feet)    of 

source     of    water     supply , 


100 

Inspector. 

BOARD  OF  HEALTH  OF  THE  STATE  OF  NEW  JERSEY 
Division  of  Creameries  and  Dairies 

Creamery  Report 

License  No Score  Allowed 

No Inspection   No Date Time a.m.   p.m 

Location    County 

Owner   Address    

Manager    Address    

Number  of  employees All  persons  engaged  in  handling 

milk    are free    from    infectious    disease. 

Number  of  patrons Quantity  of  milk  received  daily Qts. 

Average  butter  fat  test  for  dairies  at  present 

Milk  train  leaves  daily  at a.m.,  p.m.     On 

Railroad      Branch 

Method  of  Pasteurizing Machine  used 

Cream  is  made  by  hand-skimming,  separating 

Butter,  cheese,  condensed  milk,  casein,  ice  cream  or  milk  sugar  are 

made   on   the   premises 

Board  of  health  rules  are posted.     Source  of  ice  supply 


148  HYGIENE 

SHIPMENTS  TO  CUSTOMERS 


Name Address    

Cans /Cases  Mi"k.  Cans /Cases  Cream. 

Name Address    

Cans /Cases  Milk.  Cans /Cases  Cream. 

Name Address    

Cans  /Cases  Milk.  Cans  /Cases  Cream. 

Name Address   

Cans  /Cases  Milk.  Cans  /Cases  Cream, 

Name Address    

Cans  /Cases  Milk.  Cans  /Cases  Cream. 

Perfect 
Score     Allow 

1  Premises  surrounding  creamery  are clean 2       

2  Receiving    room    is partitioned    off   from    main    milk 

room 2  

3  Weigh  vacS  and  storage  tanks  are covered  when  in  use ...       4       

4  M  Ik-handling    room    is used    exclusively    for    handling 

mi!k    1  

5  I-s separate  from  where  cans  are  washed 1  

6  Is separate  from  where  engine  or  boiler  is  located 1  

7  Is well  lighted  by windows 2  

8  All  odors  and  steam  are carried  to  the  outside  air 3  

9  Walls  and  ceiling  are sheathed  and  dust  tight 2  

10  Are painted  with  some  light-colored  paint 1  

11  All  ledges  are clean  and  free  from  dust  and  dirt 2  

12  Floors  are free  from  dirt,  rubbish,  or  pools  of  drainage.  .  .        2  

13  Are made  of  concrete,  stone,  or  some  non-absorbent  material .  .  5  

14  Are water   tight 2  

15  Are so  graded  that  all  drainage  is  discharged  at  one  or 

more  points 2  

16  Strainers  in  floor  are at  least  6  inches  in  diameter 1  

17  Space  beneath  creamery  is dry 3  

18  Is free  from  waste  or  rubbish 1  

19  Drains  are of  earthenware  or  iron 2  

20  Are watertight    2  

21  Are continuous  from  the  floor  level  to  point  of  disposal.  . ..  2  

22  Are protected  against  freezing 1  

23  Drainage  is satisfactorily  disposed  of 

5        

24  Milk  pumps  and  pipes  for  milk  can be  readily  taken 

apart 1  

25  Are thoroughly  cleaned  daily 2  

26  All  steam  and  water  pipes  are painted  and  clean 1  

27  Milk  vats  are in  good  repair 1  

28  All  tin  joints  are soldered  flush 1  

29  Are thoroughly  cleaned  daily 2  

30  Milk  cans  are washed  with  hot  water  and  washing  solution       2        

3 1  Are rinsed  out  with  clean  water 1        

32  Are exposed  to  live  steam  for  at  least  two  minutes 2       


SPECIAL  RURAL  HYGIENE  149 

Perfect  Al- 

score  lowed 

33  All  milk  is protected  from  dust,  dirt,  and  flies  while  in 

pools 2       

34  Is protected  while  in  mixing  vats  or  over  aerators 2       

35  Is received  at  a  temperature  not  above  60°F 3        

36  Is kept  below  50°  while  held  or  handled  on  premises 2        

37  Cooling  tanks  are water  tight 1 

38  Are made  of  some  non-absorbent  material 1        

39  Are supplied  daily  with  clean  water  or  filled  with  clean  ice,  1      

40  Water  supply  is ample   for  all  the   needs  of  the 

creamery    5        

41  Water  supply  is apparently  free  from  all  contamination 

and  is  from 10     

42  Storage  tank  for  water  is cleaned  regularly 1        

43  Is covered  or  protected  from  dirt 1        

44  Attendants  are cleanly  in  their  habits 2        

45  Garments  worn  by  such  employees  are clean 2        

46  Privy,  water  closet,  earth  closet,  tight  vault  is satisfac- 

torily  located 2       

47  Is in  a  cleanly  condition 1        

48  Spitting  or  smoking  in  any  part  of  the  building  is )^^i 

allowed 1        

49  Domestic  animals  are allowed  in  creamery 1        

Remarks    


100     

.Inspector. 


Dressed  meats  and  federal  inspection. — This  is  a  matter  of  international 
importance,  and  yet  great  variation  exists  in  the  requirements  of  different 
governments.  The  principal  difference  is  due  to  the  fact  that  some  countries 
allow  the  locally  diseased  animals  to  be  sold  after  the  diseased  portion  is 
removed.  In  Germany  and  some  other  lands  this  meat  must  be  sold  as 
second  grade  and  with  the  warning  that  it  must  be  very  thoroughly  cooked. 
Unfortunately,  most  countries  sell  locally  diseased  meat  (of  course  removing 
pathologic  tissues)  without  any  classification  or  warning. 

In  the  United  States  the  federal  government  makes  most  elaborate 
inspection  of  all  meats  for  export.  I  have  watched  this  process  and  it  im- 
presses me  as  ideal  and  the  inspectors  highly  skilled  in  their  work.  Such 
inspection  is  so  detailed  that  a  description  of  the  whole  process  would  exceed 
our  present  limits.  Such  carcasses  as  become  merchandise  in  interstate 
commerce  are  well  inspected,  but  the  states  must  legislate  for  themselves. 
Many  of  them  have  not  done  so  and  the  great  mass  of  meat  sold  in  this  coun- 
try is  not  subject  to  any  kind  of  public  supervision.  Many  cities  have  local 
ordinances  regulating  slaughter  houses  and  abbattoirs.  Such  ordinances 
should  require  the  erection  and  use  by  all  butchers  of  a  public  slaughter  house 
under  professional  supervision  and  inspection  of  animals  and  carcasses.  All 
private  houses  should  be  abolished. 

As  to  rural  and  unskilled  inspection,  it  may  be  said  that  it  is  difficult  to 


150  HYGIENE 

estimate  the  condition  of  an  animal  before  slaughter,  unless  it  has  some  de- 
veloped disease.  In  the  Appendix  of  this  book  there  is  an  article  upon  the 
diseases  of  animals  transmissible  to  man.  After  an  animal  is  killed  it  may- 
be examined  as  follows:  Note  the  nature  of  the  fat  as  well  as  its  amount.  It 
should  be  firm  and  not  deep  yellow  in  color  nor  show  points  where  blood 
has  exuded,  but  its  appearance  is  influenced  by  the  food  and  by  the  age  of  the 
animal.  The  flesh  should  have  no  unpleasant  odor  and  should  be  fairly  dry, 
and  a  purple  or  livid  appearance  is  suspicious.  The  bone-marrow  of  the 
hind  legs  remains  solid  for  one  day  at  least  after  slaughter,  and  if  it  is  found 
soft  and  have  lost  its  rosy  red  color,  it  is  probable  the  animal  was  diseased. 
Carefully  examine  the  internal  organs  for  tumors,  tubercles,  and  suppuration 
and  a  low  power  glass  (twenty-five  to  fifty  diameters)  will  assist  in  such  ex- 
amination and  reveal  any  parasites  present. 

Poultry. —  The  common  practice  of  allowing  poultry  about  the  dairy- 
should  be  done  away  with,  as  they  carry  infection  upon  their  feet  and  foul  the 
surroundings.  Pigeons  should  not  be  kept  upon  dairy  farms  using  cistern 
water,  since  they  foul  the  roof  from  which  the  water  comes.  Diseased  poultry 
may  often  be  cured,  but  when  I  raised  several  hundred  chickens  at  a  time,  I 
found  it  paid  to  cut  the  head  off  of  a  sick  bird  and  to  bury  the  body  and  cover 
it  withvlime.     I  knew  then  that  it  was  quarantined  thoroughly. 

In  the  thirty-ninth  annual  report  of  the  Massachusetts  State  Board  of 
Health,  very  elaborate  and  detailed  researches  appear  relating  to  poultry 
kept  in  cold  storage.  The  conclusions  reached  were  so  definite  and  of  such 
value  that  they  are  reproduced  here: 

GENERAL  CONCLUSIONS 

1.  Poultry  kept  at  temperatures  ranging  from  -f"  5°  to  —  14°  F.  undergoes  no 
decomposition  as  a  result  of  bacterial  activity. 

2.  Freezing  destroys  the  red  and  some  of  the  white  blood  corpuscles. 

3.  Freezing  temperatures  as  low  as  —  14°  F.  destroy  a  large  percentage  of  the 
bacteria  present,  but  do  not  affect  the  more  resistant  ones. 

4.  When  the  tissues  are  thawed,  they  become  moistened  by  the  melting  ice  crys- 
tals, and  in  this  condition  bacterial  growth  is  facilitated  and  decomposition  of  the 
tissues  and  contents  of  the  cells  is  promoted. 

5.  In  the  drawn  chickens  placed  in  cold  storage  aerobic  conditions  prevailed 
throughout  the  pleuro-peritoneal  cavities.  The  undrawn  chickens  showed  much 
smaller  numbers  of  bacteria  in  the  pleuro-peritoneal  cavities.  On  account  of  the 
closed  cavity,  partial  anaerobic  conditions  prevailed  in  these  birds. 

In  decomposing  meats,  putrefactive  aerobic  bacteria  may  possibly  produce  the 
primary  stages  and  prepare  the  way  for  anaerobes  which  possibly  control  the  inter- 
mediate stages  of  decomposition.  By  the  combined  action  of  bo^h,  decay  is  brought 
about,  but  it  is  probably  finished  by  aerobic  bacteria. 

From  these  facts  it  appears  that,  given  the  aerobic  conditions  and  the  larger 
numbers  of  bacteria  growing  on  the  moist  surfaces  and  tissues  of  a  thawed  drawn 
chicken,  decomposition  will  proceed  at  a  more  rapid  rate  than  with  an  undrawn  one 
containing  fewer  bacteria  existing  under  partial  anaerobic  conditions. 

6.  In  freshly  killed,  unfrozen  drawn  chickens,  the  surfaces  and  tissues  become 
dry  within  a  very  short  time,  and  although  aerobic  conditions  prevail,  the  bacteria 
cannot  grow  because  of  lack  of  moisture. 


SPECIAL  RURAL  HYGIENE  151 

7.  In  freshly  kiiled,  unfrozen,  and  undrawn  chickens,  on  account  of  the  closed 
pleuro-peritoneal  cavivies  there  is  no  drying  of  the  tissues  and  surfaces,  and  facultative 
aerobic  and  anaerobic  bacteria  from  the  intestines  rapidly  cause  decomposition. 

8.  By  the  removal  of  the  viscera  without  the  spilling  of  the  contents  of  the  ali- 
mentary tract  decomposition  can  be  prevented  absolutely.  The  operation  requires 
about  two  minutes. 

9.  Briefly  stated,  decomposition  depends  largely  upon  the  presence  of  moisture 
in  the  tissues,  for  moisture  is  absolutely  essential  to  bacterial  growth.  In  freshly 
killed  birds,  ordinarily  or  properly  drawn,  the  surfaces  quickly  become  dry.  In  cold- 
storage  birds,  no  matter  how  they  are  drawn,  the  tissues  will  be  moist,  because  of  the 
melting  of  the  crystals  of  ice.  If  properly  drawn,  there  would  be  but  few  bacteria 
present  capable  of  causing  decomposition. 

Eggs. —  There  are  many  shiftless  farmers  and  hosts  of  city  people  who 
rarely  taste  a  really  first-class  egg.  "  Just  eggs  "  and  "  cooking  eggs  "  are 
common  enough,  and  they  should  never  be  used  raw  or  but  partly  cooked. 
It  is  dijB&cult  to  estimate  how  much  illness  may  or  may  not  be  caused  by  non- 
negotiable  eggs,  but  it  is  certain  that  good  ones  are  safer  and  to  be  preferred. 
I  found  that  it  paid  to  keep  fine  birds  and  to  house  and  feed  them  well.  It  is 
impossible  for  mongrel  hens  living  upon  the  dungheap  to  lay  good  eggs,  and 
only  a  long-sufFering  public  being  kept  in  ignorance  of  what  really  eggs  are 
like  prevents  an  outcry  against  the  wretched  conditions  so  commonly  existing. 
There  is  Httle  excuse,  apart  from  the  desire  for  gain,  to  pack  eggs  for  any 
length  of  time.  They  are  markedly  inferior  in  every  way  and  there  is  some 
question  as  to  their  healthfulness.  If  hens  are  warmly  housed  and  fed  upon 
warm  food  on  cold  mornings,  they  lay  fairly  well  through  the  winter.  It  is 
claimed  that  avian  tuberculosis  in  hens  may  cause  the  eggs  to  contain  bacilli, 
but  I  have  seen  no  definite  proof  of  the  claim.  Eggs  may  be  safely  kept  in 
cold  storage  for  some  time. 

Food  preservatives  and  dyestuffs. —  Chapter  XXI  discusses  this  question 
pretty  thoroughly  and  there  is  occasion  to  say  but  little  here.  The  fanciful 
names  given  to  such  substances  sold  to  farmers  creates  the  impression  that 
they  are  original  and  safe  substances.  As  a  matter  of  fact,  they  are  all  com- 
posed of  substances  outlawed  in  many  of  the  states  and  many  are  prohibited 
in  interstate  commerce. 

Fish  and  game  meats. —  The  sale  of  these  products  out  of  season  is  illegal 
in  many  states,  and  in  a  few  states  the  sale  of  some  of  them  is  altogether 
prohibited.  The  clandestine  sale  of  these  perishable  meats  results  in  much 
of  it  being  kept  too  long  and  sold  when  tainted.  I  believe  these  prohibitory 
laws  are  against  public  policy  and  are  unfair  to  the  owner  of  rural  property. 
They  are  devised  at  the  behest  of  professional  hunters  and  "  sportsmen,"  a 
class  who  are  an  unmitigated  nuisance  to  the  farmer.  No  amount  of  foolish 
legislation,  like  protecting  bear,  will  prevent  the  farmer  from  killing  bear  that 
raid  his  property.  If  rabbits  are  girdling  a  farmer's  trees  he  is  apt  to  kill 
them  in  season  or  out  of  season.  I  do  not  advocate  breaking  law,  but  the 
farmer  and  the  sanitarian  should  be  considered  before  the  selfish  "  sports- 
man "  when  fish  and  game  laws  are  drawn.  It  is  the  height  of  folly  to  allow 
the  killing  of  game  in  inaccessible  regions  by  persons  having  no  facilities  to 


152  HYGIENE 

properly  ship  it  to  market,  and  yet  prevent  the  residents  who  are  in  position 
to  take  sanitary  care  of  the  meat  from  kilUng  more  than  one  or  two  animals 
in  a  season.     The  result  is  that  the  game  reaching  market  is  often  unfit  to  eat. 

Insecticides  upon  food. —  The  free  use  of  Paris  green  and  of  powdered 
hellebore  may  lead  to  the  consumer  being  poisoned,  but  actual  instances  are 
so  rare  that  the  danger  is  not  at  all  imminent.  Tobacco  stems,  lime,  sulphur, 
land  plaster,  coal  oil  emulsion,  and  other  rather  safe  substances,  are  more 
generally  used,  and  Paris  green  very  rarely  except  upon  potatoes,  which,  being 
a  root  crop,  are  not  reached  by  the  chemical.  Ordinary  care  will  prevent  any 
danger  from  insecticides. 

Poisonous  plants  and  their  eradication. —  Too  few  trees  and  too  many 
weeds  are  a  common  condition  upon  the  farm.  Trees  die  too  young  and 
weeds  live  too  long.  If  you  think  your  trees  will  not  respond  to  kindly  treat- 
ment and  live  to  a  green  old  age,  read  "  The  Tree  Doctor,"  by  John  Davey, 
of  Kent,  Ohio,  and  be  convinced.  It  would  amaze  an  Ohio  or  New  York 
farmer  to  see  the  weeds  of  the  South.  They  grow  there  as  if  they  meant  to 
"  stay  put,"  and  they  usually  do  stay.  Mere  weeds  usually  do  little  harm 
except  to  crowd  out  other  more  useful  vegetation,  but  so  many  species  are 
poisonous  or  do  harm  to  cattle  and  horses  that  the  farmer  should  know  con- 
siderable of  botany.  Weeds  should  not  be  allowed  to  choke  up  the  margins 
of  streams  and  ponds,  as  they  not  only  are  apt  to  decay  and  produce  offensive 
conditions,  but  they  also  prevent  the  natural  enemies  of  mosquitoes  from  reach- 
ing them.  Rag  weed  and  golden-rod  along  public  roads  induce  hay  fever  in 
many  susceptible  persons  and  should  be  removed.  Some  varieties  of  wind- 
flower  poison  cattle  and  even  so  common  a  plant  as  starwort  may  do  the  same 
thing.  Crawford  has  shown  that  certain  plants  take  up  barium  from  the 
soil  in  quantities  sufficient  to  produce  "  loco  "  in  animals.  Different  regions 
have  their  special  plant  problems.  The  following  is  clipped  from  a  news- 
paper: 

Waco,  Texas.,  May  9. —  The  alarming  destruction  of  Texas  trees  through  the 
agency  of  the  poisonous  mistletoe  has  induced  M.  B.  Davis,  secretary  of  the  Texas 
Audubon  Society,  to  sound  a  warning  to  those  interested  in  trees  to  destroy  the  mis- 
tletoe before  it  in  turn  denudes  the  state  of  its  forests. 

"Every  municipality  in  Texas  is  afflicted  with  the  pest,  and  it  has  been  stated  by  an 
authority  that  the  life  of  a  tree  when  thoroughly  inoculated  with  the  mistletoe  poison 
will  terminate  in  about  seven  years,"  says  Mr.  Davis.  "  It  is  carried  from  one  tree  to 
another  by  certain  birds  feeding  on  the  berries,  and  wherever  it  finds  lodgment  on  trees 
susceptible  to  its  deadly  parasitic  growth  its  blight  proves  fatal  in  time,  unless  heroic 
treatment  is  applied.  At  this  season,  while  the  evergreen  parasite  is  clearly  discernible 
upon  the  bare  boughs,  the  work  should  be  done. 

"  The  Texas  mistletoe  (phoradendron  flavencens)  differs  materially  from  its 
kindred  parasite  evergreen  of  Europe  (viscum  album),  which  is  kept  in  check  in  the  old 
world,  but  cultivated  to  some  extent  for  winter  decoration.  The  variety  in  the  cotton 
states  is  far  more  pernicious  and  must  be  wholly  exterminated  or  the  trees  will  all 
perish  from  its  baleful  blight.  Any  one  may  observe  from  car  windows  that  entire 
forests  are  being  killed  by  mistletoe. 

"  It  is  a  beautiful,  but  horrible,  parasite,  and  can  be  destroyed  finally  only  by 
cutting  off  the  entire  bough  on  which  its  growth  appears.     The  hackberry,  which  is 


SPECIAL  RURAL  HYGIENE 


153 


popular  in  cities  as  a  shade  tree,  is  one  of  the  favorites  of  these  poisonous  parasites, 
and  in  nearly  every  city  in  this  state  where  hackberry  trees  have  been  planted  about 
twenty-five  per  cent  of  them  have  already  died  from  mistletoe  poison." 

Many  other  plants  have  a  host.  A  familiar  instance  is  the  wheat  rust 
known  as  Puccinia  gra minis,  which  has  its  cluster-cup  stage  on  the  leaves 
of  barberry  in  June.  The  spores  are  carried  by  the  wind  to  the  wheat. 
Ergot  or  smut  on  rye  and  corn  is  quite  poisonous  and  should  be  removed 
when  found.     It  must  be  used  for  some  time  for  spurred  rye  or  corn  to  cause 


OULdAM/^HA 


A  Few  Common  or  Dangerous  Weeds 

Anemone  is  poisonous  to  cattle.  Celandine  is  an  irritant  poison  externally. 
Capsella  is  a  nuisance  in  pastures  and  is  apt  to  harm  the  kidneys  of  cattle.  Dulcamara 
is  a  narcotic  poison.  Conium  is  a  dangerous  poison.  Agaricus  is  the  poisonous 
mushroom. 

serious  symptoms.  Vetch  should  not  be  used  as  food,  as  it  induces  symptoms 
similar  to  those  produced  by  the  castor  be^n.  Pellagra  is  a  disease  of  some 
importance  in  parts  of  the  South  and  it  is  caused  by  damaged  Indian  corn  or 
corn  cut  when  immature  or  stored  in  damp  and  bad  surroundings.     Many 


154  HYGIENE 

fungi  and  mildews  cause  disease  under  certain  circumstances.  The  "  dry 
rot "  fungus  causes  immense  damage  to  timber.  Mushrooms  must  be  care- 
fully identified  before  they  are  eaten.  As  a  matter  of  fact,  they  possess  very 
little  food  value.  This  whole  class  of  plants  are  hard  to  eradicate,  and  the 
best  that  can  be  done  is  to  practice  clean  farming  and  to  look  after  the  forest 
growth  and  to  drain  bogs. 

Weeds  are  legion;  common  ones  being  the  thistles,  wire  and  wild  grasses, 
burs,  ticks,  dodder,  wild  mustard,  burdock,  chicory,  cockle,  daisies,  dandelion, 
dock,  nettles,  narcotic  herbs,  pigweed,  plantain,  purslane,  ragweed,  capsella, 
sorrel,  and  many  species  escaped  from  cultivation.  Good  cultivation  mark- 
edly reduces  the  number  of  weeds,  while  others  must  be  pulled  up  after  a 
long  rain  or  grubbed  out.  A  few,  like  the  artichoke,  are  destroyed  by  hogs 
rooting  for  the  tubers.  Garhc  and  other  plants  eaten  by  cattle,  and  that 
taint  the  milk,  are  difficult  of  eradication. 

Some  berries,  such  as  those  of  phytolacca  or  poke,  attract  children  and 
should  be  watched  and  the  youngsters  taught  the  danger.  Monkshood  and 
other  ranunculaceae  will  readily  kill  cattle.  Poison  ivy  should  be  pulled 
down  and  burned.  Toxic  plants  are  so  numerous  that  our  space  precludes  a 
full  description.  Coal  oil  will  kill  some  of  them,  but  care  and  cultivation  is 
the  main  reliance  and  also  planting  clean  seed  will  largely  prevent  new  pests 
from  gaining  a  foothold.  Be  careful  of  new  flowers,  I  had  great  difficulty 
getting  rid  of  the  Japanese  lantern  plant  and  a  rapid  growing  morning  glory. 
It  is  probably  of  greater  importance  to  eradicate  poisonous  weeds  than  is  com- 
monly thought  to  be  the  case,  but  the  main  danger  is  upon  the  dairy  farm. 

Insect  pests  require  little  discussion  here.  Mosquitoes  are  considered  in 
other  chapters.  We  do  not  have  the  tsete  fly  m  this  country,  but  blow  flies, 
cheese  mites,  the  bee  moth  that  spoils  the  honey  in  the  interior  of  hives,  mites 
and  worms  infesting  grain  and  beans,  worms  infesting  fruit,  and  many  other 
species  are  more  or  less  of  a  menace  to  health  and  lead  to  industrial  losses. 
The  agricultural  bureaus  and  the  state  entomological  departments  give 
detailed  direction  for  the  destruction  of  these  pests. 

Sanitation  in  sending  produce  to  market. —  This  is  largely  a  matter  of 
good  roads,  good  transportation,  and  a  ready  market.  The  farmer  and 
trucker  are  blamed  for  many  things  for  which  they  are  not  responsible.  I 
have  seen  commission  houses  in  the  large  cities  seriously  neglect  the  produce 
in  their  hands  and,  when  the  market  was  bad  from  their  own  point  of  view, 
sell  wilted  and  decayed  vegetables  and  fruit  that  was  received  in  good  order. 
The  granges  and  farmers'  organizations  could  do  a  real  service  to  sanitation 
by  bringing  some  of  these  foreign  produce  dealers  to  book.  They  should  not 
be  permitted  to  store  good  truck  and  hold  it  for  a  rise  and  sell  their  share  then 
and  dump  the  other  half  off"  the  dock.  So  called  "  gluts  "  are  largely  fictitious 
or  are  produced  by  car  famines.  It  is  hard  for  the  small  shipper  to  get  proper 
icing  facilities,  and  the  large  shipper  owns  his  own  cars  and  icing  stations,  gets 
to  market  first  because  they  can  send  a  man  with  the  train  to  prevent  side- 
tracking, and  can  undersell  the  small  owner.  Fortunately  conditions  are 
improving.  The  Interstate  Commerce  Commission  is  forbidding  freight 
rebates,  the  railroads  are  providing  better  cars,  the  public  is  demanding  better 


SPECIAL  RURAL  HYGIENE 


155 


produce,  the  sanitary  authorities  are  being  more  strict,  the  pure  food  laws  are 
stopping  the  excessive  use  of  agents  to  prevent  decay,  and  the  commission 
merchants  are  objecting  to  the  Italian  and  other  careless  merchants  bringing 
the  business  into  disrepute.  One  great  factor  to  produce  better  market  con- 
ditions is  the  very  great  extension  of  trolley  service.  Milk  and  perishable 
freight  is  gathered  up  and  delivered  expeditiously  by  this  service.  Free  rural 
mail  delivery  and  the  use  of  the  telephone  are  placing  the  farmer  in  touch  with 
the  market.  But  if  any  one  thinks  there  is  not  room  for  improvement,  let 
him  watch  the  freight  yards  and  terminals,  the  docks  and  wharves,  and  the 
commission  houses.  However,  there  is  no  occasion  for  pessimism.  All  that 
is  needed  is  publicity,  as  in  the  exposure  of  stockyard  conditions  and  "  em- 
balmed meat,"  and  whatever  abuses  still  exist  will  soon  come  to  an  end. 

Summer  camps. —  The  sanitation  of  large  camps  is  considered  in  Chapter 
XII.  Small  camps  are  peculiarly  liable  to  enteric  and  malarial  fevers,  and 
the  precautions  to  be  observed  are  in  the  direction  of  water  supply,  the  avoid- 
ance of  mosquitoes  and  the  disposal  of  waste  as  covered  under  different 
headings  in  this  book.  Camp  meetings,  as  formerly  conducted,  had  few 
sanitary  arrangements,  but  the  modern  assemblies  and  chautauquasare  usu- 
ally well  conducted,  although  the  cottages  are  built  unnecessarily  close  to- 
gether. 


OECAYINC- 


From  the  Mud  taken  from  a  Mountain  Brook 


Rural  resorts. —  The  Twenty-eighth  Annual  Report  of  the  New  York 
State  Department  of  Health  reports  a  condition  of  affairs  paralleled  in  many 
other  states.     The  following  is  from  the  report: 


SANITARY  CONDITION  OF  SUMMER  RESORTS 

This  investigation  comprises  a  series  of  visits  or  inspections  of  summer  hotels 
in  the  state.  On  one  railroad  line  alone  are  o  be  found  nearly  two  thousand  boarding 
houses  or  hotels,  the  capacity  of  which  is  not  far  from  fifty  thousand  people.  A  large 
number  of  these  are  under  the  superv  sion  of  the  health  officer  of  the  village  or  town 
where  they  happen  to  be  located.  Bm  mountain  camps,  farm  boarding  houses,  and 
even  large  hotels  in  the  mountains  are  often  beyond  vhe  reach  of  regular  health  officers, 


156  HYGIENE 

even  if  a  small  community  felt  justified  in  assuming  such  control  and  attendant 
expense. 

It  would  appear,  therefore,  that  if  the  large  number  of  summer  recreation  seekers 
are  to  be  pro-  ected  in  health  while  at  summer  hotels,  the  protection  must  come  from 
the  state  authorities.  The  conditions  in  existence  at  present  have  been  found  to  be 
revolting  in  the  extreme.  In  several  cases  drinking  water  was  taken  from  a  shallow 
well,  surrounded  by  privies  and  cesspools.  In  a  number  of  cases  the  sewer  of  the  hotel 
discharged  into  the  same  pond  or  lake  from  which  the  water  supply  for  the  house  was 
taken,  and  only  a  few  feet  away.  In  one  hotel,  indeed,  the  two  pipes  were  laid  in  the 
same  trench  to  save  expense.  In  about  seventy-five  per  cent  of  the  places  inspected, 
the  conditions  were  not  seriously  bad,  but  in  the  other  twenty-five  per  cent  the  condi- 
tions called  for  immediate  remedy. 

Owmg  to  lack  of  adequate  engineering  assistance  this  investigation  was  onlv  par- 
tially completed.  The  information  that  was  secured,  however,  was  at  once  utilized, 
and  notices  were  sent  to  all  offending  parties  that  the  sanitary  conditions  must  be 
remedied  before  the  opening  of  the  next  season.  In  addition  to  these  notices,  con- 
siderable advice  was  given  as  to  the  nature,  extent  of  the  improvement,  and  in  some 
cases  the  type  and  arrangement  of  disposal  plants,  that  would  meet  the  requirements 
of  this  department. 

The  results  of  this  investigation  show  so  clearly  the  danger  that  lies  in  the  unsani- 
tary conditions  surrounding  many  summer  resorts  and  the  importance  of  protecting 
this  growing  population  of  pleasure  and  health  seekers,  that  it  is  important  that  this 
work  be  continued  and  extended  in  the  future. 


f.  ^ 


» t*r^>«V'^  ■— "    ^     Til  If  '^/i*^Lm  •l^ 


PUMPING       RIVER  COAL      TWENTY  MILES  BELOW  THE  MINES 

THE    ABANDONED    CANAL.       A    RURAL    PERIL 

MACHINE    FOR    DRILLING    DEEP    WELLS 


Chapter  IX 

STATE  DEPARTMENTS  AND  BOARDS  OF  HEALTH* 

Introductory  remarks. —  An  outline  of  their  legal  basis  in  the  states  and  terri- 
tories— The  legal  powers  and  limitations  of  state  departments — The  importance  of 
keeping  up  with  the  regulations  in  force  in  one's  own  state — What  obligations  rest 
upon  the  general  practitioner — The  vaccination  problem — Reports  expected  of  phy- 
sicians— Vi'al  statistics — Local  represen-  atives  of  state  organizations — ^Their  rela- 
tionship to  local  health  boards — Misunderstandings  and  disputes  and  how  to  avoid 
them — The  charity  and  emergency  work  of  state  departments  and  how  the  physi- 
cian can  co-operate  therein — A  brief  outline  of  their  status  in  the  various  states — 
Where  to  secure  bulletins  of  the  laws  and  regulations  of  the  states. 

He  can  hoist  a  yellow  flag  over  a  center  of  civilization  and  turn  it  into  a  desert  ; 
he  can  hoist  a  Red  Cross  in  the  desert  and  turn  it  into  a  center  of  civilization. 

If  he  judges  it  necessary  to  the  success  of  any  operation  in  which  he  is  interested 
he  can  halt  a  twenty  thousand  ton  liner  with  her  mails,  in  midocean,  till  he  has  finished 
that  operation. 

He  can  forbid  any  ship  to  enter  any  port  in  the  world;  he  can  tie  up  the  traffic 
of  any  port  in  the  world  without  notice  given. 

He  can  order  houses,  streets,  whole  quarters  of  cities  to  be  pulled  down  or  burned 
up,  and  if  his  patients  object  to  the  prescription  he  can  count  on  the  armed  co-operation 
of  the  nearest  troops  to  see  that  his  orders  are  obeyed. 

—  Rudyard  Ktpling. 

ONE  of  the  first  questions  recorded  in  history  was,  "  Am  I  my  brother's 
keeper  ?  "     From  thirty  centuries  ago,  the  physician  has  answered 
it  in  the  affirmative.     True,  he  construed  the  word  brother  in  the 
singular.     To-day,  he  gives  it  a  plural  significance. 

The  world  of  fiction  is  rich  in  pictures  of  the  erstwhile  conventional 
doctor,  full  of  mystery  and  sympathy,  but  obsessed  with  the  vast  diflTerence 
between  the  doctor  and  the  layman  and  an  exalted  impression  of  his  own 
prerogative.  To  him  the  relationship  between  his  patient  and  himself  was 
so  sacred  that  public  interest  was  a  matter  apart  and  none  of  his  concern. 
In  these  days  we  may  forget  some  of  the  finer  attributes  so  fully  possessed  by 
him,  and  we  cannot  but  admire  the  rugged  commonsense  of  our  medical 
ancestors. 

But  a  new  era  has  dawned  upon  the  world.  Nations  are  being  drawn 
together,  and  the  means  of  communication  are  so  extended  that  the  old  and 
careless  ways  are  dangerous,  and  society  is  forced  to  look  after  the  health  of 
its  units  in  order  to  preserve  the  whole  fabric.  It  is  the  old  saying  over  again, 
"  like  priest,  like  people  "  ;  only  it  is  the  doctor  this  time,  and  not  the  priest. 
It  is  very  easy  for  the  physician  to  complacently  assume  that  the  profession 
leads  the  people,  but  it  would  be  difficult  to  prove  it;  the  rather  is  it  easy  to 
show  that  nearly  all  medical  advance  parallels  that  of  other  fields  of  endeavor 

*Prepared  from  the  reports  and  other  literature  of  every  state  board  in  the  United 
States  and  in  the  territories.     Legal  data  by  Samuel  H.  Orwig,  A.M.,  LL.B. 


158  HYGIENE 

and  the  branches  of  pure  science.  Dogma  and  empiricism  can  be  evolved  in  a 
cloister  or  at  the  desk,  but  the  modern  tendency  of  medicine  has  been  to  apply 
the  data  derived  by  experimentation  and  the  conclusions  of  the  biologist, 
physicist,  and  chemist. 

Colonization  enterprises,  large  engineering  works,  the  extension  of  trade, 
the  development  of  the  tropics,  foreign  missionary  effort,  the  aggression  of 
war  and  "  the  white  man's  burden  "  are  factors  that  created  international 
medicine.  We  have  been  insular  here.  "  States'  rights  "  have  taken  pre- 
cedence of  national  obligations.  If  we  want  to  be  a  world  power  we  must 
take  our  national  part  in  the  world.  We  look  to  a  nation  and  not  to  one  of  its 
provinces  or  departments,  and  the  nations  look  to  our  federal  government 
and  not  to  the  states. 

But  the  government  at  Washington  looks  to  the  states.  Federal  obliga- 
tions regarding  sanitation  have  been  largely  diverted  to  places  under  military 
control;  but  the  various  bureaus  are  establishing  connections  with  state  work, 
and  such  things  as  the  Interstate  Commerce  Commission  and  the  Pure  Food 
and  Drug  Act  are  rapidly  extending  the  national  interest  in  what  is  of  im- 
portance in  matters  of  health  and  sanitation.  A  national  department  or 
bureau  of  health  will  doubtless  be  established,  and  the  states  will  very  sud- 
denly become  aware  of  the  demands  this  department  will  make.  Many  of 
the  states  have  anticipated  these  demands  and  are  elaborating  state  medicine 
in  a  very  efficient  manner.  It  is  inevitable  that  all  of  the  states  will  come  to 
regard  themselves  as  simple  units  in  a  national  scheme  of  sanitation. 

The  writer  is  old  enough  in  the  profession  to  belong  to  the  old  order  of 
things,  when  we  studied  under  preceptors  and  expected  to  find"  laudable 
pus  "  and  other  disagreeable  things  considered  as  inevitable.  Men  like 
myself  can  have  little  sympathy  with  the  idea  advanced  in  England  that  the 
time  will  soon  be  that  the  doctor  will  wear  a  state  uniform  and  live  upon  a 
state  salary.  Such  ideas  rudely  wrench  all  that  we  hold  dear  in  the  profession. 
An  experienced  man  is  also  liable  to  resent  interference  with  his  work,  espe- 
cially when  it  comes  from  some  very  young  official.  But  it  is  well  for  us  to 
remember  that  the  old  order  has  departed  and  that  we  must  get  new  marching 
orders  or  be  left  in  the  rear  by  the  younger  men.  It  is  also  well  to  bear  in 
mind  that  the  health  authorities  have  their  own  troubles  and  are  limited  by 
very  definite  laws.  Very  few  heads  of  departments  are  inclined  to  exact  the 
unreasonable.  They  are  sharply  restricted  in  their  work.  So  long  as  the 
American  system  of  national  and  state  financial  appropriation  is  vested  in 
popular  legislative  bodies,  just  so  long  v/ill  the  more  or  less  creditable  politi- 
cian dominate  even  health  boards,  to  some  extent. 

But  the  politician  is  improving.  There  is  a  general  uplift  in  the  air, 
and  the  things  that  might  justly  be  subject  to  criticism  in  the  work  of  some 
of  the  state  health  boards  are  being  eliminated.  I  am  sure  that  the  excel- 
lent gentlemen  at  the  heads  of  these  boards  over  the  country  are  doing  the 
very  best  they  can  and  often  under  very  trying  circumstances.  They  regret 
just  as  much  as  does  any  practicing  physician,  that  the  exigencies  of  politics 
and  the  newness  of  the  work  are  responsible  for  the  fact  that  some  incom- 
petent men  are  upon  their  payrolls.     They  also  think  that  it  is  a  pity  that  so 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  159 

many  incompetent  men  are  practicing  medicine  and  failing  to  appreciate 
the  fact  that  no  man,  in  any  line  of  work,  may  legally  carry  on  his  business 
unless  he  makes  all  proper  effort  to  protect  the  public  from  whatever  dangers 
or  perils  are  incident  to  that  business. 

Weak  human  nature  is  responsible  for  practically  all  of  the  friction  with 
the  profession  and  the  public  that  has  been  engendered  in  the  work  of  quali- 
fied sanitary  authorities.  After  this  function  of  the  nation  and  the  state  is 
fully  understood,  and  the  newness  of  it  all  wears  off,  there  will  be  little  trouble. 
Poor  officials  will  be  eliminated,  and  the  whole  machine  will  run  more 
smoothly.  It  is  incumbent  upon  all  physicians  to  be  patient  and  uphold  all 
proper  and  honest  effort  upon  the  part  of  the  state  to  improve  the  health  of 
its  citizens.  It  is  true  we  should  insist  upon  our  own  proper  prerogatives, 
but  we  should  not  do  so  rashly.  If  the  mass  of  the  profession  display  the 
proper  spirit,  the  officials  will  not  limit  our  own  initiative  within  our  own  field 
of  effort.  It  is  very  easy  for  the  departments  and  the  profession  to  cultivate 
cordial  and  harmonious  relations,  and  that  should  always  be  done.  One  way 
to  do  so  is  for  the  physicians  to  make  an  effort  to  get  real  practicing  doctors 
and  not  mere  theorists  upon  these  boards.  Such  officials  better  understand 
the  situation  confronting  us. 

Salus  Populi  Suprema  Lex 

Every  well-organized  government  has  the  inherent  right  to  protect  the 
health  and  provide  for  the  safety  and  welfare  of  its  people.  This  inherent 
right  is  tantamount  to  a  duty  of  the  sovereign  power  to  the  public  under 
its  jurisdiction. 

The  authority  to  enforce  this  obligation  is  vested  in  what  is  termed 
"  the  police  power,"  and  originally  and  inherently  belongs  in  the  United 
States  of  America  to  the  states  and  not  to  the  federal  government,  save  in 
exceptional  cases. 

In  the  absence  of  statutory  regulations,  or  acts  of  assembly,  the  common 
law  affords  sufficient  authority  to  enforce  what  measures  may  be  necessary  to 
protect  the  health  of  the  community,  and  to  indict  in  the  courts  offenders 
against  necessary  orders  from  constituted  authority. 

By  reason  of  the  innumerable  occasions  of  offense  against  necessary 
sanitary  measures,  whether  excited  by  malice,  gain,  an  indifference  to  the 
welfare  of  others,  or  by  ignorance  upon  the  part  of  the  offender,  it  is  diffi- 
cult to  set  the  limits  within  which  the  police  power  may  be  exercised. 

Happily  for  the  inhabitants  of  most  of  the  states  of  the  American  Union, 
this  police  power,  so  far  as  it  relates  to  the  public  health,  is  defined  and 
limited  by  statutes  which,  for  the  time,  appear  to  define  the  limits  and  pro- 
vide more  specifically  and  certainly  for  the  protection  of  the  public  health 
and  the  welfare  of  the  people,  and  to  avoid  arbitrary  and  unjust  action.  But 
even  these  statutes,  as  experience  has  shown,  not  infrequently  need  revision, 
amendment,  and  judicial  interpretation. 

"  The  police  power  "  is  a  broad  and  comprehensive  one,  by  which  the 
rights  of  an  individual,  both  as  to  his  liberty  and  his  enjoyment  of  property, 


160  HYGIENE 

may  be  curtailed  in  the  interest  of  the  public  welfare.  When  laws  enacted  by 
virtue  of  an  exercise  of  the  police  power  interfere  with  the  citizen's  liberty  or 
rights  of  property,  they  can  only  be  justified  on  the  grounds  that  they,  in  some 
manner,  secure  the  comfort,  safety,  or  welfare  of  society. 

To  quarantine  persons  is  to  keep  them,  when  suspected  of  having  them- 
selves contracted  or  been  exposed  to  an  infectious  or  contagious  disease  in 
another  person,  out  of  the  community,  or  to  confine  them  to  a  given  place 
therein,  thus  preventing  intercourse  between  them  and  the  people  generally. 
The  general  law  warrants  such  quarantine,  but  in  order  to  make  it  effective 
enabling  acts  must  be  passed  designating  through  what  officers  and  under 
what  conditions  quarantine  may  be  enforced. 

The  relationship  of  the  medical  profession  and  the  police  power  of  the 
state,  cit},  borough,  or  other  governmental  unit,  when  defined  by  legislative 
enactment,  must  be  determined  in  every  instance  by  the  words  of  the  statute, 
subject  (as  in  other  cases)  to  judicial  interpretation. 

Having  thus  considered  the  legal  competence  of  the  state  to  ordain  and 
execute  sanitary  legislation,  it  is  of  interest  to  inquire  to  what  extent  it  is  prac- 
ticable and  wise  to  execute  these  prerogatives.  This  can  be  best  answered  by 
telling  what  has  been  done  by  the  authorities  of  the  several  commonwealths  of 
the  Union.  We  will  do  so  at  large,  since  it  would  require  a  volume  itself  to 
narrate  the  multitudinous  activities  in  detail.  As  to  the  ultimate  extent  of 
state  medicine,  we  should  not  care  to  hazard  a  guess.  Piobably  the  degree 
of  wisdom  actuating  the  officials  having  in  charge  this  important  work  will 
be  the  determining  factor  in  public  support.  Without  popular  interest  and 
support  no  such  work  can  survive  in  this  country.  This  fact  is  a  guarantee  of 
discreet  and  conservative  management,  and  it  is  more  than  probable  that  the 
United  States  will  witness  within  its  several  commonwealths  the  greatest 
official  sanitary  and  public  health  measures  ever  undertaken  in  the  world. 

The  United  States  Government  does  not  undertake  to  officially  guide  the 
states  in  the  enactment  of  legislation  rendering  operative  the  state  police 
power  in  the  enforcement  of  sanitary  measures,  but  the  various  bureaus  and 
the  Public  Health  and  Marine  Hospital  Service  and  its  hygienic  laboratory  at 
Washington  are  co-operating  with  the  state  authorities  in  elaborating  the 
details  of  legislation  and  administration  necessary  for  the  practical  conduct  of 
an  efficient  state  work.  As  has  been  said,  an  act  of  assembly  is  necessary 
to  the  carrying  out  of  an  effective  state  work.  In  such  states  as  have  legis- 
lated upon  the  subject  some  variation  is  apparent,  but  the  underlying  power 
of  each  state  varies  but  little  in  capacity.  Therefore,  the  possible  limits  of 
actual  work  are  nearly  similar.  Based  upon  no  one  state,  we  will  consider 
the  question  of  how  far  the  state  is  actually  enforcing  sanitary  legislation 
to-day. 

The  state  takes  the  view  that  there  must  be  an  executive  at  the  head  of 
any  department;  and  it  makes  it  the  duty  of  the  state  commissioner  of  health 
(some  states  use  a  different  title)  to  protect  the  health  of  the  citizenship  and 
alien  residents  of  the  commonwealth,  but  the  details  incident  thereto  are 
vested  largely  in  his  own  discretion.     This  makes  him  a  very  powerful  official. 

Some  of  the  states  provide  for  an  advisory  board  of  physicians  and  lay- 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  161 

men  trained  in  sanitation  or  its  engineering  features,  and  there  are  various 
provisions  for  the  co-operation  of  the  legal  and  executive  officers  of  the  state. 
In  states  with  seaports  the  national  and  state  quarantine  regulations  must  not 
conflict  with  merely  local  measures,  and  this  requires  especial  provision. 
States  bordering  upon  foreign  countries  have  their  own  problems  to  work  out 
as  regards  quarantine.  To  facilitate  practical  administration,  most  state 
departments  are  divided  into  divisions,  having  each  its  head.  The  number 
of  these  subordinate  offices  is  determined  by  the  range  of  work  undertaken  by 
the  state  department.  This  will  be  touched  upon  later.  A  field  organiza- 
tion is  usually  effected  or  arrangements  made  for  local  co-operation  with  the 
central  organization,  A  well-organized  department  is  in  constant  touch 
with  the  whole  state  and  its  work  and  problems.  This  is  usually  all  provided 
for  by  special  enactment. 

Anything  regarded  as  a  nuisance  or  inimical  to  health  or  life  within  the 
commonwealth  comes  under  the  dominion  of  the  department.  Any  state 
can  give  the  officials  of  the  health  department  the  right  to  enter,  examine, 
and  survey  any  and  all  places  so  offending  and  to  order  the  abatement  of  the 
fault  and  to  enforce  the  order  and  assess  costs.  Most  state  departments 
possess  all  of  or  a  portion  of  these  powers.  Some  states  grant  the  right  of 
forcible  entry  and  impose  penalties  upon  violators  of  department  orders  and 
with  interference  with  the  duties  of  the  department  or  of  its  agents  in  the 
discharge  of  their  duties.  Vital  statistics  and  the  work  of  physicians,  mid- 
wives,  nurses,  and  undertakers,  with  reference  to  vital  statistics  and  the  re- 
porting of  infectious  diseases,  all  come  under  the  departments  or  a  division  to 
which  it  assigns  this  work.  In  some  states  local  registrars  are  appointed 
to  look  after  vital  statistics  in  a  county  or  district.  As  many  as  one  thousand 
such  registrars  exist  in  some  states. 

A  few  legislatures  have  given  the  state  department  the  right  to  revoke 
or  modify  local  regulations  or  ordinances  when  they  appear  to  be  contrary  to 
public  policy  as  regards  sanitation  outside  their  own  district  or  territory, 
Except  in  so  far  as  the  state  waterways  are  involved  or  in  time  of  epidemic, 
such  powets  are  seldom  invoked  and  some  persons  call  in  question  the  wis- 
dom of  such  enactment.  However,  it  is  often  so  imperative  that  something 
be  done  in  time  of  epidemic,  that  it  is  considered  legal  to  vest  large  discre- 
tionary powers  in  a  state  health  department.  There  is  always  the  protection 
of  the  courts  for  persons  who  feel  aggrieved  or  injured,  and  it  is  not  likely  that 
a  department  will  forget  this  fact  and  do  harsh  things,  except  when  they  are 
necessary. 

Sheriffs,  constables,  and  police  officers  may  be  required  by  a  state  de- 
partment to  make  arrests,  help  maintain  quarantine,  or  do  any  act  devolving 
upon  them  under  the  law. 

Nearly  all  state  departments  have  a  division  of  medical  inspection  with 
many  sanitary  agents  scattered  over  the  state.  This  phase  of  work  is  dis- 
cussed in  Chapter  XI  of  this  book,  and  need  not  be  entered  into  here.  Vital 
statistics  will  also  be  discussed  later  in  this  present  chapter. 

A  sanitary  engineering  division  is  really  essential  to  a  state  department. 
The  work  of  sanitary  engineers  is  touched  upon  under  several  chapters  in  this 


162  HYGIENE 

book.  Here  we  are  interested  in  the  legal  powers  of  such  a  division.  All 
states  have  large  rights  over  their  waterways,  and  this  gives  state  health 
departments  a  large  measure  of  control  over  municipal  or  corporate  water- 
works and  sewage  systems.  There  is  no  doubt  but  that  the  state  does  have 
the  right  to  control  such  matters  to  a  large  degree.  There  is  a  tendency  to 
object  to  government  by  commission,  but  this  can  hardly  be  classed  under 
that  category,  especially  as  the  work  of  the  division  is  largely  of  a  helpful  rather 
than  a  prohibitory  nature. 

All  corporations  are  subject  to  state  laws  or  regulations,  and  water  com- 
panies must  obey  the  sanitary  laws  and  build  and  equip  their  plants  under 
state  supervision,  provided  the  state  so  exacts.  A  larger  question  is  involved 
in  maintaining  a  clean  watershed,  and  much  care  and  tact  is  required  upon 
the  part  of  the  state  to  maintain  these  sheds  as  they  should  be  kept.  The 
engineering  division  does  this  work  in  part  and  it  has  large  powers  that  are 
seldom  invoked  in  full.  As  ideal  conditions  cost  so  much,  the  carrying  out 
of  some  orders  cannot  be  borne  by  individuals  and  the  state  cannot  undertake 
it  all  at  once.  The  state  can  demand  that  sewage,  not  already  so  discharging, 
must  be  kept  out  of  streams  or  waterways.  Some  states  make  the  claim  that 
extending  an  existing  sewer  system  gives  the  state  department  the  right  to 
demand  that  such  extension  forfeits  the  right  to  discharge  any  sewage  from 
the  old  system  into  the  streams.  Cases  exist  where  the  state  department  has 
ordered  a  municipality  to  make  changes  in  its  system  of  sewers  of  so  costly  a 
nature  as  to  require  the  bonding  of  the  municipality  beyond  its  debt  capacity. 
In  such  event  the  courts  must  review  the  matter  and  the  engineering  division 
must  be  patient,  since  two  laws  must  not  be  brought  into  conflict. 

In  all  such  cases  or  in  others  where  an  injustice  would  be  done  by  the 
state  in  rigidly  enforcing  the  law,  conferences  with  those  involved  usually 
result  in  a  certain  extension  of  time  for  the  completion  of  changes  deemed 
necessary  for  sanitary  reasons.  Legislatures  are  also  asked  to  make  appro- 
priations of  state  funds  to  do  such  things  as  cannot  be  completed  by  the 
municipalities. 

It  goes  without  saying  that  state  departments  of  health  may  legally  under- 
take certain  charity  work,  such  as  the  free  distribution  of  diphtheria  anti- 
toxin (see  Chapter  XVI)  and  tuberculosis  dispensaries  being  maintained  for 
the  free  treatment  of  the  poor.     (See  Chapter  XIX.) 

The  importance  of  keeping  up  unth  the  regulations  in  force  in  one's  own 
state. —  It  should  never  be  forgotten  that  a  state  department  of  health  con- 
stitutes an  expansion  of  the  medical  prerogative  and  the  work  of  the  medical 
profession.  Lawyers  are  so  accustomed  to  look  to  the  courts  that  they  all 
finally  become  officers  of  the  court.  That  is  what  admission  to  the  bar  really 
means.  The  courts  and  the  administration  of  justice  are  ingrained  parts  of 
the  lawyer's  existence.  Physicians  have,  as  a  class,  avoided  politics  and 
have  felt  little  public  obligation.  Their  opinion  has  not  been  sought  in 
matters  they  have  avoided  and  the  profession  has  lost  caste,  to  some  extent, 
by  reason  of  our  isolation.  But  this  day  is  passing,  and  we  cannot  afford  to 
fold  our  hands  and  "  view  with  alarm  "  the  publicity  that  is  beginning  to 
beset  the  work  of  the  doctor.     Let  us  learn  from  our  friends  of  the  legal 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  163 

profession  and  realize  that  we  should  hold  the  same  relationship  to  the  sani- 
tary authorities  as  do  the  lawyers  to  the  courts.  We  should  be  officers  of  the 
state  so  far  as  public  health  is  concerned.  We  should  not  dominate  the 
health  departments,  but  we  should  hold  ourselves  in  readiness  to  aid  in  their 
work. 

In  this  view  of  the  case,  if  it  ever  prevails,  rests  one  of  the  great  hopes  of 
state  medicine  and  the  greatest  opportunity  of  the  medical  profession  to  serve 
the  public.  But  ignorant  loyalty  to  a  cult,  a  religion,  a  ruler,  a  cause,  or  a 
department  of  health,  never  accomplished  much  of  permanent  value.  In- 
telligent  service  alone  avails  to  save  a  nation  or  a  cause,  and  equally  is  it  true 
that  intelligent  service  is  necessary  to  preserve  the  health  and  wellbeing  of 
any  people.  Hence,  our  proper  course  is  very  clear.  "  Ignorance  of  the 
law  excuses  no  man,"  and  particularly  is  it  true  that  ignorance  of  the  laws 
governing  his  own  environment  and  calling  are  inexcusable.  One  trade 
and  business  after  the  other  have  been  subjected  to  regulation  and  legal 
supervision,  and,  while  there  has  been  some  friction,  the  ultimate  result  has 
been  to  improve  the  condition  of  every  legitimate  interest  involved.  Such 
things  as  would  not  stand  the  light  of  day  have  suffered  and  have  deserved  to 
suffer.  Whatever  there  may  be  of  weakness  in  the  theories  and  practice  of 
medicine  must  give  way  to  the  intelligence  of  the  twentieth  century,  and  what- 
ever there  is  of  strength  and  usefulness  must  have  the  protection  and  aid  of 
the  public  and  of  public  law. 

We  need  fear  nothing  from  the  operation  of  health  department  legisla- 
tion, but  it  imposes  a  responsibility  upon  us.  This  we  should  not  evade.  We 
will  be  short-sighted  if  we  attempt  to  do  so.  "  No  man  liveth  to  himself 
and  no  man  dieth  to  himself,"  and  the  day  is  long  since  set  in  the  mist  of 
superstition  in  which  the  physician  could  afford  to  try  so  monastic  a  role  in 
life.  We  owe  it  to  our  fellows  in  the  profession  that  has  honored  us,  to  honor 
the  laws  that  help  us  individually  to  honor  the  profession.  This  is  no  "  vicious 
cycle,"  but  the  good  one  akin  to  — "  Better  fifty  years  of  Europe  than  a  cycle 
of  Cathay."     We  are  living  in  the  best  fifty  years,  or  let  us  hope  so. 

At  the  end  of  this  chapter  will  be  found  such  data  as  is  necessary  for  some 
general  understanding  of  conditions  in  one's  own  state.  There  is  a  bulky 
publication  issued  covering  all  the  legislation  and  rulings  of  the  several  state 
departments,  but  three  months  after  issuance  it  begins  to  need  revision. 
Hence,  it  is  quite  impossible  for  us  here  to  attempt  an  analysis  of  the  state 
regulations  in  detail.  The  members  of  the  profession  who  are  actively  in- 
terested in  the  practical  working  out  of  the  problems  involved  in  state  medi- 
cine should  study  the  matter  at  first  hand,  and  in  the  offices  and  field  work  of 
such  state  departments  as  they  may  find  access  to  and  are  near  at  hand.  As 
to  the  general  practitioner  of  medicine,  it  is  his  duty  to  carefully  read  the  cir- 
culars sent  to  him  by  the  department  of  his  own  state,  or  to  send  for  new  ones 
if  he  has  neglected  the  matter  in  the  past.  Especially  is  it  necessary  for  him 
to  find  out  the  definite  laws  and  regulations  to  which  he  is  subject.  If  he 
thinks  any  of  these  laws  or  regulations  are  unjust  or  oppressive,  let  him  take 
up  the  matter  in  his  local  medical  society  and  compare  notes  with  his  fellows. 
Perhaps  he  may  see  the  wisdom  of  the  law  as  expressed  by  the  discussion,  or 


164  HYGIENE 

some  better  plan  may  be  presented  that  the  department  will  be  glad  to  hear 
about.  Such  discussions  are  very  interesting  when  the  local  health  officials 
take  a  part  and  narrate  some  of  their  experiences.  It  is  well  to  bear  in  mind 
that  the  various  state  departments  issue  new  rulings  at  intervals  and  they 
should  be  carefully  studied. 

What  obligations  rest  upon  the  general  practitioner. —  These  obligations 
are  of  two  kinds,  legal  and  moral.  Roughly  stated,  the  legal  obligation  is  to 
protect  the  public  by  obeying  the  laws  provided  for  this  purpose.  In  detail 
we  cannot  adequately  discuss  the  matter  in  our  limited  space.  Suffice  it  to 
say  that  the  general  practitioner  must  meet  the  situation  differently  in  city 
and  in  country  practice.  It  is  not  intended  by  state  departments  to  set  aside 
proper  local  regulation,  but  rather  to  supplement  such  measures.  In  conse- 
quence one  usually  finds  that  the  cities  carry  out  most  of  the  detail  so  far  as 
the  individual  physician  is  concerned.  In  a  city  one  reports  to  the  city 
health  officials  (in  most  states),  while  in  a  rural  locality  some  county  represen- 
tative may  represent  the  state  department  or  said  department  may  supply 
proper  blanks  for  direct  reports. 

It  is  well  to  remember  that  the  law  is  no  respecter  of  persons,  and  that 
prominence  in  the  community  or  social  position  does  not  render  a  family  or 
an  individual  immune  to  the  quarantine  and  other  regulations  of  the  sani- 
tary or  health  departments.  The  physician  has  no  right  to  make  such  dis- 
tinctions. Furthermore,  neglect  to  report  infectious  disease  may  render  the 
family  or  its  responsible  head  equally  guilty  before  the  law  with  the  physician. 

All  courts  exact  of  a  physician  that  he  possess  the  average  degree  of  skill 
and  learning  found  among  the  doctors  of  his  district.  As  regards  the  matters 
we  are  discussing,  all  physicians  are  expected  to  so  inform  themselves  as  to 
be  able  to  diagnose  the  infectious  diseases  common  to  their  locality.  Let 
me  commend  a  study  of  Chapter  XV.  In  case  one  is  not  able  to  arrive  at  a 
diagnosis,  it  is  his  duty  to  call  a  consultant  or  to  report  the  matter  to  the 
proper  authorities.  It  does  not  compromise  a  physician  in  the  least  to  admit 
ignorance  of  some  disease.  The  writer  has  never  seen  a  case  of  yellow  fever. 
Am  I  in  a  position  to  diagnose  a  case  ?  Here  in  Harrisburg  we  have  filtered 
water  and  almost  no  typhoid  fever.  In  course  of  time  we  may  have  physi- 
cians of  several  years'  practice  and  yet  have  never  treated  a  case  of  this 
disease.     Will  they  be  able  to  diagnose  typhoid  ? 

It  would  be  strange  if  we  did  not  have  some  dishonest  men  in  the  medi- 
cal profession.  Unfortunately,  these  men  are  called  in  to  reverse  the  diag- 
noses of  honest  men  called  into  families  who  wish  to  resist  quarantine.  It  is 
always  disagreeable  when  this  occurs,  and  all  of  us  have  lost  families  by 
obeying  the  law.  Usually  we  are  helpless  except  to  keep  track  of  these  cases 
and  these  alleged  doctors  and  report  the  facts  to  the  local  medical  society. 
Where  the  case  is  dangerous  or  the  facts  seem  to  warrant  it,  we  can  report 
such  differences  to  the  health  authorities  and  let  them  decide  the  matter.  If 
the  local  board  is  made  up  of  ordinary  politicians,  and  the  alleged  doctor  has 
*'  a  pull,"  we  may  just  as  well  save  ourselves  the  trouble,  for  nothing  will  be 
done  except  to  discredit  the  honest  man.  But  honest  differences  in  opinion 
occur.     In  the  midst  of  writing  the  last  paragraph,  I  was  called  to  a  village 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  165 

in  an  adjoining  county  in  which  several  cases  exist  of  both  measles  and  scarlet 
fever,  and  it  is  hard  to  differentiate  between  them.  In  some  houses  both  dis- 
eases have  appeared.  Measles  is  quarantined  for  twenty-one  days  and 
scarlet  fever  for  thirty  days  (in  that  county)  and  the  residents  are  angry  at 
physicians  who  impose  the  longer  quarantine  or  who  report  second  cases  in 
the  same  house  and  thus  extend  the  time  limit.  I  realized  that  the  local  phy- 
sicians are  facing  a  disagreeable  situation.  In  other  chapters  the  details  of 
local  regulation  will  be  discussed. 

One  thing  much  neglected  by  physicians  and  yet  expected  by  the  state  is 
some  understanding  of  diseases  transmitted  by  animals  to  man.  Bubonic 
plague,  anthrax,  actinomycosis,  glanders,  hydrophobia,  trichiniasis,  foot  and 
mouth  disease,  and  others,  are  readily  transmitted  to  man  and  are  a  real 
menace.  In  the  appendix  of  this  book  they  are  given  some  description. 
Moral  obligations  are  too  well  understood  to  need  discussion  here. 

The  vaccination  problem. —  The  national  government  undertakes, 
through  the  Public  Health  and  Marine  Hospital  Service,  the  supervision  of 
vaccine  production  necessary  to  ensure  its  safety  from  contamination  and 
impurities.  Persons  in  the  federal  service  are  subject  to  the  regulations  of 
the  department  in  which  they  are  employed,  and  must  submit  to  vaccination 
when  required.  The  states  face  a  different  problem.  A  general  compulsory 
vaccination  law  similar  to  that  of  Germany  could  not  be  enforced  in  most 
communities  in  the  United  States,  Any  state  exercises  authority  over  its 
schools  and  can  enact  a  law  making  school  attendance  obligatory  and  requir- 
ing the  vaccination  of  all  who  attend.  Some  states  have  done  this  and  the 
general  results  have  been  good.  However,  there  has  arisen  certain  conflict 
in  some  states,  and  the  law  in  such  cases  has  failed  of  complete  enforcement. 
Probably  the  provisions  of  some  of  these  laws  is  a  little  harsh,  but  the  matter 
is  being  carefully  studied  and  objectionable  features  are  being  eliminated. 
There  is  no  doubt  that  the  opponents  of  vaccination  exaggerate  the  degree  of 
objection  to  the  school  laws.  The  school  and  health  bureau  records  of  Phila- 
delphia show  that  less  than  fifty  children  out  of  two  hundred  thousand  remain 
out  of  school  because  of  parental  opposition  to  vaccination.  In  case  of  great 
peril  from  epidemics  of  smallpox,  the  state  authorities  have  little  trouble  in 
inducing  the  great  majority  of  people  to  be  vaccinated.  Chapters  III  and 
XVI  discuss  the  vaccination  question  in  detail. 

Reports  expected  of  physicians. —  Nearly  all  cities  maintain  a  board  or 
bureau  of  health  or  sanitation,  the  official  names  varying  greatly.  In  order 
to  facilitate  the  conduct  of  quarantine  and  other  measures,  most  departments 
of  health  in  the  various  states  require  the  physician  to  report  infectious  dis- 
ease to  the  cit}  board,  and  it,  in  turn,  transmits  the  data  to  the  state  depart- 
ment. Most  cities  provide  blank  reports  and  proper  postage  for  such  re- 
turns.    The  following  is  a  fair  example  of  a  city  report: 

CITY  OF SANITARY  DEPARTMENT 

Report  of  communicable  disease;  of  one  or  more  cases  in  one  family.  This 
report  must  be  made  within  twenty-four  hours  by  a  physician. 


166  HYGIENE 

Notice. —  The  following  is  an  extract  from  the  Act  of  Assembly  approved . 

(Then  follows  the  extract.)     Or  it  may  be  quotations  from  city  legislation.     A  list  of 
reportable  diseases  may  be  given. 

Disease Date  of  first  symptoms 

Name  of  patient Sex Age 

Residence  of  patient 

No.  of  persons  in  family, ;  male, ages, ;  £,....  ages .  .  . 

Others  exposed  ? 

Name  and  address  of  attending  physician 

Date 

Some  cities  require  the  physician  to  telephone  or  send  messenger  in  case 
of  smallpox  or  where  the  health  of  the  community  is  seriously  endangered. 
There  is  some  conflict  in  regard  to  the  very  common  requirement  to  report 
within  twenty-four  hours.  It  may  be  construed  as  twenty-four  hours  after  first 
seeing  the  case  or  twenty-four  hours  after  diagnosis.  The  language  should 
be  specific  and  should  make  allowance  for  the  delay  required  in  typhoid  and 
other  cases  one  cannot  always  diagnose  at  the  first  visit.  There  is  a  danger 
of  too  great  haste  in  diagnosing  and  reporting  a  case,  since  follicular  tonsil- 
litis may  be  mistaken  for  diphtheria,  malarial  fever  for  typhoid,  etc.  Young 
physidans  should  be  especially  careful  in  this  regard,  as  they  are  less  apt  to 
have  seen  many  cases  of  some  of  the  infectious  diseases. 

In  rural  districts  or  in  the  absence  of  a  health  board  the  report  is  made  to  a 
health  officer  designated  by  the  state  authorities  and  notice  of  whose  appoint- 
ment is  sent  to  the  physicians  of  the  district.  The  following  data,  or  some- 
thing very  similar,  appears  upon  the  notification  cards: 

DISEASES  TO  BE  Commonwealth  of 

REPORTED  DEPARTMENT  OF  PUBLIC  HEALTH   ' 

Actinomycosis  19. . 

Anthrax 

Bubonic  plague  Patient Nativity 

Cerebrospinal  Age Sex Color Occupation 

meningitis 

Chickenpox  Address    

Cholera 

Diphtheria  County Township 

Epidemic  dysentery 

Erysipelas  Disease Date  of  onset 

German  measles 

Glanders  Name  of  householder   


Hydrophobia 

Leprosy  Occupation  of  householder 

Malarial  fever 

Measles  Number  of  school  children School 

Mumps 

Pneumonia  (True)  M.D. 

Puerperal  fever 

Relapsing  fever  Address    

Scarlet  fever 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  167 

Smallpox  Reports  of  smallpox  cases  should  be  telephoned  or  telegraphed 

Tetanus  to  the  County  Medical  Inspector. 

Trachoma 

Trichiniasis  By  order  of M.D. 

Tuberculosis 

Typhoid  fever  Commissioner  of  Public  Health. 

Typhus  fever 

Whooping  cough  N.B. —  Mail  this  Card  Promptly. 

Yellow  fever 

Some  states  do  not  include  so  extended  a  list  of  diseases,  nor  are  all  re- 
portable diseases  quarantined.  One  must  consult  the  regulations  of  his  own 
state  to  be  guided  in  this  matter.  But  wherever  the  physician  lives,  the  gen- 
eral principle  rules  that  he  should  promptly  report  all  cases  as  required  by  his 
home  officials. 

Cities  may  or  may  not  require  the  reporting  of  further  data  and  the 
event  of  the  recovery  of  the  patient.  In  most  of  them,  there  are  so  many 
sanitary  authorities  that  such  reports  are  made  by  them,  or  the  length  of 
quarantine  automatically  terminates  and  the  sanitary  officer  fumigates  and 
disinfects  the  premises  and  removes  the  placard.  In  rural  sections  the  de- 
partment is  notified  of  the  termination  of  the  case  by  sending  in  a  report 
similar  to  this: 

Commonwealth  of 

DEPARTMENT  OF  PUBLIC  HEALTH 

To 

Health  Officer 

living  at in 

(Patient) 

ffully  recovered 

Twp.,  has       -|    or  from    

I^died  (disease) 

Please  disinfect  and  release  from  quarantine  and  isolation. 

M.D. 

Address 

Date 

Note:  Physicians  will  please  note  rooms  which  should  be  disinfected 


The  writer  has  examined  the  blank  reports  from  many  cities  and  states, 
and  submits  the  above  as  based  upon  those  of  Pennsylvania  and  its  cities,  and 
as,  in  his  judgment,  being  so  well  adapted  to  the  work  as  to  merit  reproduc- 
tion and  as  serving  as  a  guide  for  districts  and  states  not  satisfied  with  their 
own  forms.  But,  where  medical  health  officers  are  employed,  shorter  blanks 
serve  every  purpose.     (See  Chapter  XI.) 

The  twenty-four  hour  limit  for  report  should,  in  my  opinion,  be  defined 
as  to  its  exact  meaning,  by  a  footnote. 


168  HYGIENE 

Vital  statistics  have  never  interested  the  general  practitioner  very  greatly, 
and  most  of  us  lag  somev^hat  in  reporting  the  cases  of  minor  infection,  such 
as  whooping  cough  and  mumps.  We  are  inclined  to  argue  that  as  these  cases 
are  not  quarantined  (they  are  in  Pennsylvania),  why  should  we  go  to  the 
trouble  to  report  them.  Probably  a  monthly  report  of  some  of  these  matters 
might  relieve  the  physician  somewhat,  but  it  is  questionable  if  it  would  result 
in  more  full  reports.  The  safer  plan  is  for  the  physician  to  assume  that  he 
knows  only  one  locality  and  is  ignorant  of  conditions  elsewhere,  and  the  state 
authorities  may  very  badly  need  data  from  all  sources  in  order  to  determine 
their  course  of  action  in  regard  to  some  threatening  disease.  Measles  may  be 
very  mild  in  one  section  and  be  a  fatal  scourge  in  another  section.  This  is  a 
disease  commonly  neglected,  and  that  should  be  always  reported.  I  have 
seen  an  epidemic  of  whooping  cough  develop  many  fatal  cases.  This  matter 
is  important  and  physicians  assume  too  much  when  they  denounce  the  laws 
regarding  the  collection  of  vital  statistics.  And  the  public  is  at  fault  very 
often.  We  have  many  Pennsylvania  German  people  in  this  district,  and  they 
see  no  reason  for  sending  for  a  physician  in  a  case  of  minor  infection  or  what 
they  choose  to  regard  as  such.  In  my  own  families  I  often  am  asked  for  school 
permits  after  a  child  has  recovered  from  measles  or  some  other  disease  and  in 
which  no  physician  was  called  to  see  the  case  and  of  which  I  have  no  knowledge 
until  after  the  recovery.  For  these  and  other  reasons  vital  statistics  in  this 
region  are  apt  to  be  very  far  short  of  the  real  facts.  It  is  the  duty  of  the 
physicians  and  of  the  public  to  make  an  effort  to  improve  upon  the  past  in 
this  regard. 

Physicians  who  are  legally  registered  are  state  officers  in  regard  to  the 
reporting  of  births,  deaths,  and  disease.  They  should  feel  both  the  honor 
and  the  responsibility  that  devolves  upon  them  therein. 

In  reporting  births,  much  may  be  at  stake  years  after,  since  these  reports 
are  permanent  records  and  constitute  legal  proof  in  some  actions  at  law.  One 
should  be  careful  to  supply  correct  data  and  be  upon  his  guard  as  to  writing 
into  a  certificate  the  name  of  the  alleged  father  in  case  of  an  illegitimate  birth. 
There  is  a  tendency  upon  the  part  of  some  authorities  to  demand  the  reporting 
of  all  miscarriages  and  abortions.  There  is  no  doubt  that  such  demand  is 
fair  from  a  legal  point  of  view,  and  the  physician  is  protected  in  certain  cases; 
but  there  are  unfortunate  incidents  in  so  many  good  families  that  it  would  be 
outrageous  to  make  public  their  shame.  If  reports  of  such  cases  are  demanded, 
it  is  incumbent  upon  the  authorities  to  preserve  inviolate  all  such  data.  This 
is  nearly  impossible,  especially  in  states  where  registrars  get  this  data  and 
where  the  reports  are  made  matters  of  public  record.  I  have  known  in- 
stances where  a  report  of  such  a  case  would  have  resulted  in  the  physician 
being  either  thrashed  or  shot. 

The  Bertillon  system  of  disease  classification  has  been  adopted  in  many 
states,  in  an  effort  to  make  uniform  the  vital  statistics  of  the  different  states 
and  countries.  Physicians  can  assist  in  this  work  by  filling  out  death  cer- 
tificates in  an  intelligent  manner  and  avoiding  indefinite  or  vague  terms  or 
disease  names.  Such  terms  as  "  heart  failure  "  and  those  indicative  of  a 
mere  symptom  should  not  be  used.     By  comparing  the  census  returns  with 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  169 

the  vital  statistics,  much  very  valuable  data  and  conclusions  are  elicited.  This 
object  is  defeated  unless  the  reports  are  approximately  accurate.  This  is 
equally  true  of  the  reports  of  marriages  by  clergymen  and  magistrates  and  the 
reports  of  the  midwives  and  undertakers. 

As  illustrative  of  the  importance  of  carefully  gathered  vital  statistics, 
permit  me  to  quote  from  the  message  of  the  governor  of  Pennsylvania  to  the 
legislature  of  1897: 

The  need  of  a  suitable  system  of  registration  of  vital  statistics  is  also  being  con- 
stantly brought  to  the  attention  of  the  health  authorities.  In  an  enlightened  com- 
munity there  live  but  few  people  of  mature  age  whose  birth,  marriage,  or  death  does 
not  at  some  time  become  a  matter  for  the  cognizance  and  consideration  of  legal  author- 
ities. The  attainment  of  majority  with  its  rights  and  duties,  the  fact  and  date  of  wed- 
lock, the  inheritance  or  conveyance  of  property,  parentage,  and  nationality,  place, 
date  and  cause  of  death  and  interment,  and  many  other  questions  of  sociologic,  eco- 
nomic, and  even  historical  character  often  assume  much  importance  with  reference  to 
many  of  our  citizens.  In  the  absence  of  a  state  system  of  registration  many  of  the 
citizens  are  deprived  of  their  legal  rights  or  are  enabled  to  deprive  their  fellows  of  their 
legal  rights. 

The  deeds  of  the  murderer  and  abortionist  or  the  suicide  can  be  easily  concealed 
from  human  view  until  decomposition  has  obliterated  all  evidence  of  the  crime. 

Local  representatives  of  state  organizations. —  The  duties  of  these  gentle- 
men are  defined  in  another  chapter  in  more  detail  than  is  necessary  here. 
In  order  for  the  state  to  fully  prosecute  its  work,  it  is  essential  that  it  be  repre- 
sented by  trained  men  who  have  a  proper  executive  over  them,  and  thus  the 
"  team  work  "  so  essential  for  any  definite  results  is  quickly  attained.  Time 
means  much  in  state  medicine  and  it  requires  "  minute  men  "  to  carry  into 
effect  the  orders  of  the  state  officials  just  as  much  as  it  requires  trained  firemen 
to  fight  our  fires. 

Their  relationship  to  local  health  hoards. —  This  is  largely  advisory,  and 
to  do  the  disagreeable  things  that  must  be  done  but  that  the  cousins  and  the 
uncles  and  the  aunts  (as  well  as  the  patients  and  the  political  friends)  of  the 
local  men  ptoceed  to  make  too  hot  for  him  to  do.  It  is  the  same  old  question 
of  the  use  of  local  militia  to  quell  a  local  riot.  It  takes  state  police  or  soldiers 
from  elsewhere  to  maintain  order.  Sickness  is  a  strange  influence  mixed  with 
superstition  and  fanaticism,  in  the  minds  of  so  many,  that  it  is  all  but  impos- 
sible to  make  othei"wise  normal  people  take  a  sane  view  of  the  problem.  The 
folly  of  the  clergy  in  trying  to  meet  the  inroads  of  alleged  "  Christian  Science  " 
and  other  mystical  cults  is  an  illustration  of  the  tendency  of  this  hystero- 
strenuous  age.  All  this  makes  it  hard  to  keep  people  from  deliberately  run- 
ning their  heads  against  a  stone  wall.  The  laws  make  it  a  misdemeanor  to 
attempt  suicide  by  fast  means,  and  the  authorities  must  not  allow  people  to 
do  the  same  thing  by  slower  methods.  Some  one  must  be  responsible,  and 
in  this  instance  it  is  the  local  representative  of  state  medicine.  It  must  be 
remembered  that  these  men  are  the  friends  of  all  who  obey  the  laws,  and  that 
is  the  duty  of  every  good  citizen. 

Misunderstandings  and  disputes  and  how  to  avoid  them. —  Lack  of  knowl- 
edge and  misinterpretation  of  men  and  things  are  responsible  for  most  dis- 


170  HYGIENE 

putes.  The  practical  administration  of  the  sanitary  laws  is  like  the  admin- 
istration of  all  other  law,  in  that  it  first  interests  itself  in  what  the  lawyers  call 
"  the  people."  But  with  sanitation,  it  really  is  the  people  and  not  the  side 
upon  which  the  district  attorney  is  alligned,  although  he  is  often  dragged  into 
a  side  against  his  will.  There  being  no  greed  for  money  back  of  sanitation 
and  the  enforcing  of  sanitary  laws,  the  "  people  "  have  an  unprejudiced  case 
every  time  and  it  is  well  for  obstructionists  to  remember  that  fact. 

On  the  other  hand,  most  legal  processes  are  in  no  hurry,  and  can  be 
removed  to  another  jurisdiction  or  postponed  or  appealed  to  a  higher  court,  or 
a  demurrer  entered  or  a  cross  suit  instituted  or  settled  out  of  court,  or  one  of 
several  kinds  of  writs  issued  and  no  end  of"  circumlocution  office  "  red  tape 
twisted  over  and  around  the  whole  proceeding.  People  are  used  to  that  sort 
of  thing  and  would  probably  be  quite  unhappy  without  it;  at  least  the  lawyers 
would  be,  but  when  it  comes  to  the  enforcement  of  sanitary  matters  these 
"  sacred  traditions  "  and  "  inalienable  rights  "  do  not  count  and  the  physi- 
cian cannot  get  half  as  much  fun  out  of  this  kind  of  law  as  does  the  rest  of 
people  out  of  theirs.  Probably  this  is  too  bad,  but  our  spoiling  the  lawyer's 
pet  way  of  doing  business  with  powdered  wig  and  mourning  robes  is  no 
worse  than  his  ripping  out  the  darling  foibles  of  the  medical  profession.  At 
all  events,  things  are  destined  to  be  done  differently  and  with  less  friction. 
However,  it  would  not  hurt  the  sanitary  authorities  to  be  as  considerate  as  is 
possible  under  the  circumstances  and  to  refrain  from  using  "  the  big  stick." 
Many  questions  of  practical  administration  are  not  in  a  hurry  and  both  sides 
should  be  patient.  Sanitary  legislation  is  rather  new,  and  it  will  take  some 
time  for  the  people  and  even  for  the  profession  to  understand  and  to  intelli- 
gently co-operate  with  the  gentlemen  who  have  given  these  matters  detailed 
and  highly  specialized  study.  One  way  to  make  the  doctors  better  under- 
stand the  situation  is  for  the  sanitary  officers  to  seek  opportunities  to  address 
the  medical  societies.  Sometimes  it  is  hard  for  others  to  fully  appreciate  the 
difficulties  of  the  general  practitioner.  It  is  equally  hard  for  him  to  com- 
prehend the  trials  of  the  sanitarian.  Strict  adherence  to  the  code  of  medical 
ethics  should  be  imposed  upon  both  sides. 

The  charity  and  emergency  work. —  Several  states  are  undertaking  such 
work.  Tuberculosis  dispensaries  and  sanitoria  are  being  established  and  are 
doing  a  great  work  that  is  fully  entered  into  in  a  separate  chapter.  Permit 
me  to  refer  the  reader  to  it  and  to  the  many  publications  so  fully  describing 
this  important  work. 

Statistics  are  said  to  he  dry  reading  and  a  mere  statistical  narration  of  the 
work  of  the  various  states  would  not  interest  the  general  practitioner.  In  order 
to  avoid  this  and  make  the  following  portion  of  this  chapter  of  real  and  live 
interest,  I  have  written  to  every  state  hoard  of  health  in  the  United  States  asking 
for  copies  of  their  latest  literature.  The  response  has  heen  most  generous  and  I 
have  made  a  careful  study  of  the  large  mass  of  interesting  reports  and  other 
official  puhlications  of  the  hoards.  By  personal  travel  and  from  federal  reports, 
I  have  added  to  this  data  and  helieve  the  suhject,  as  presented  in  an  informal 
manner,  will  he  of  interest  and  convey  much  information  to  the  reader. 

Please  do  not  omit  reading  this  portion  of  the  chapter,  hut  take  with  me  a 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  171 

survey  of  our  great  country  and  learn  the  lesson  that  YOUR  SECTION  is  not  the 
only  one  doing  a  splendid  work  in  state  medicine.  Health  officers  can  well 
afford  to  read  the  details  of  a  survey  made,  from  their  standpoint,  by  an  amateur 
hut  unbiassed  observer,  and  permit  me  to  say  to  them  that,  from  my  standpoint, 
all  hoards  have  some  weak  points  and  all  have  strong  ones.  So  have  health 
officers.  It  is  not  my  province  to  point  out  the  weak  places,  but  to  provide  a 
narration  by  which  one  can  read  between  the  lines  to  find  his  own  deficiency  and 
FROM  the  lines  may  find  a  cure. 

Alabama 

The  Medical  Association  of  the  State  of  Alabama  issues  from  Montgom- 
ery a  quite  elaborate  annual  publication  inclusive  of  its  annual  proceedings 
and  the  health  work  of  the  state.  There  is  a  state  commission  of  public 
health,  but  the  work  is  conducted  partially  under  the  auspices  of  the  medical 
association.  From  the  reports,  I  gather  that  an  adequate  work  is  being  con- 
ducted, and  it  is  to  the  credit  of  the  medical  men  of  the  state  that  their  society 
takes  so  active  a  part  therein. 

In  no  other  state  is  the  health  work  so  intimately  related  to  the  medical 
society,  although  it  was  formerly  common  in  the  South  to  conduct  state  sani- 
tation along  this  line. 

Alaska 

Dr.  C.  C.  Grieve,  of  Sitka,  writes  that  Alaska  has  no  territorial  health 
officers  or  sanitary  organization,  but  that  the  incorporated  towns,  such  as 
Juneau,  have  local  regulations  and  some  have  boards  of  health. 

Arizona 

The  Territorial  Board  of  Health  is  composed  of  the  governor,  the  attor- 
ney-general, and  the  superintendent  of  public  health.  It  is  empowered  to 
make  rules,  and  the  legislative  assembly  has  enacted  into  laws  a  full  code  of 
requirements  governing  state,  county,  and  city  sanitation.  An  examination 
of  these  laws  shows  that  they  are  in  advance  of  those  of  many  of  the  states. 
The  territory  is  now  preparing  to  establish  a  system  of  vital  statistics  similar 
to  the  Pennsylvania  division  of  vital  statistics.  Reports  are  rendered  bi- 
ennially, and  they  reveal  a  considerable  degree  of  efficiency  in  the  Arizona 
work. 

The  board  issues  a  quarterly  bulletin  with  the  suggestive  motto: 
"  Sanitation  and  strict  quarantine 
pays  big  interest  on  the  investment," 

and  the  publication  seems  to  be  a  most  practical  one.     Here  is  an  extract: 

GLOBE'S  TYPHOID  RECORD  FOR  TWO  YEARS 

Globe  has  a  health  officer  who  is  interested  in  his  work,  who  is  a  sanitarian  and 
who  does  things.     In  the  spring  of  this  year  he  instituted  a  clean-up  of  the  entire  city  — 


172  HYGIENE 

streets,  alleys,  and  yards  —  warned  the  public  of  the  danger  of  flies  and  filth  and  for 
ten  days  had  eleven  men  and  two  teams  at  work  gathering  up  and  removing  the  rubbish. 
The  city  is  kept  clean  by  rigid  inspection,  regular  removal  of  garbage,  rubbish,  and 
manure,  and  by  regulations  prohibiting  the  throwing  of  "dodgers"  and  other  paper 
about  the  streets.  Covered  receptacles  for  rubbish  are  provided  by  the  city  along  the 
main  street.  The  county  team  was  employed  and  some  work  was  done  by  the  prison- 
ers during  the  clean-up.  Dr.  Fox's  salary  was  increased  from  ^50  per  month  to  ;^100. 
Aside  from  this  the  entire  expense  of  the  clean-up  was  about  ;$500. 

Here  are  the  results: 

Male  Adult  Female  Adults  Children  Total 

Cases         Deaths    Cases       Deaths      Cases       Deaths     Cases       Deaths 


1907 

.   83 

9 

8 

8 

25 

1 

116 

12 

1908 

,  .   13 

1 

1 

1 

5 

1 

19 

3 

Saving    ...       70  8  7  1  20  0  97  9 

Seventy  men  at  ;^3.00  per  day  for  forty-five  days  (it  is  usually  figured  at 

sixty  days)  represents  a  saving  of i^9,4S0.00 

Expenses   (medical   attendance,  medicines,  nursing,  necessary  appli- 
ances) for  ninety-seven  patients  at  ;^75 7,275 .  00 

A  total  saving  of ;^16,725 .00 

Sixteen  thousand  seven  hundred  and  twenty-five  dollars  gained!  The 
joy  of  living  in  a  clean  town,  the  freedom  from  noisome  odors  and  from  un- 
sightly rubbish,  the  absence  of  worry  —  any  one  of  these  is  worth  the  five 
hundred  dollars.  And  this  takes  no  account  of  the  nine  lives  saved ,  the  value 
of  which  it  is  difl&cult  to  compute.  Talk  about  copper  mines!  Why  this  has 
them  faded  to  a  frazzle! 

Arizona  must  meet  the  tuberculosis  problem  owing  to  the  fact  that  so 
many  sufferers  take  advantage  of  its  climate.  I  figured  from  one  of  the 
quarterly  reports  of  vital  statistics  that  thirty-six  per  cent  of  the  mortality 
was  due  to  this  disease.  Flies  and  insects,  dust,  heat,  adobe  houses,  and  other 
matters,come  before  them.  The  board  is  meeting  its  obligations  to  sanitation 
very  creditably. 

Arkansas 

The  state  board  of  health  was  organized  in  1881,  and  conducts  its  work 
from  Little  Rock.  The  ordinances  of  the  state  provide  for  the  necessary  lines 
of  public  sanitation,  and  for  the  organization  of  local  boards. 

California 

The  officers  of  the  state  board  of  health  are  located  at  Sacramento,  and 
the  general  work  and  that  of  the  Bureau  of  Vital  Statistics  are  there  per- 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  173 

formed,  while  the  State  Hygienic  Laboratory  and  the  State  Food  and  Drug 
Laboratory  are  at  the  University  of  CaHfornia,  at  Berkeley. 

The  political  code  contains  acts  covering  practically  all  of  the  necessary 
regulations,  an  excellent  feature  being  that  the  exact  powers  of  the  state  and 
local  boards  are  clearly  outlined  and  defined.  Emergencies  are  well  met  by 
allowing  cities  and  counties  to  levy  a  special  tax  not  exceeding  one  fourth  of 
one  per  cent  when  such  a  tax  is  needed  for  quarantine  and  other  sanitary 
purposes.  There  is  a  good  vaccination  law  and  the  1909  act  providing  for 
the  sanitation  of  food-producing  establishments  is  almost  ideal.  The  gov- 
ernor has  recently  signed  it.  The  food  and  drug  act  is  ahead  of  most  state 
legislation  upon  the  subject.     In  general,  the  California  laws  are  admirable. 

California  has  been  blamed  with  concealing  bubonic  plague.  I  have 
never  been  there,  but  have  read  California  literature  as  well  as  that  from 
other  sources.  It  impresses  me  that  some  of  the  criticism  was  most  unjust. 
There  was  a  tendency  upon  the  part  of  the  business  interests  to  resent  the 
aggressive  action  of  the  Public  Health  and  Marine  Hospital  Service,  but  the 
health  authorities  of  the  state,  pressed  by  political  and  business  interests  as 
they  were,  maintained  a  pretty  correct  attitude  so  soon  as  they  realized  the 
situation.  There  were  individuals  who  concealed  cases,  it  is  true,  but  the 
state  authorities  cannot  be  so  blamed.  The  recent  publications  of  the  Public 
Health  and  Marine  Hospital  Service  go  into  details  concerning  the  activities  of 
the  California  authorities  and  tell  some  of  the  difficulties,  such  as  sewers 
deflected  by  the  earthquake.  Oakland  alone  spent  ^65,000  upon  plague 
measures.  The  fact  remains  that  a  prompt  and  eflFective  work  was  done 
and  California  deserves  some  of  the  credit  and  only  part  of  the  blame.  The 
following  is  1909  legislation  passed  by  the  California  Legislature: 

The  people  of  the  state  of  California,  represented  in  senate  and  assembly,  do  enact 
as  follows: 

[Section  1.]  It  shall  be  and  is  hereby  declared  to  be  the  duty  of  every  person, 
firm,  co-partnership,  company,  and  corporation,  owning,  leasing,  occupying,  possessing 
or  having  charge  of  or  dominion  over,  any  land,  place,  building,  structure,  wharf,  pier, 
dock, vessel, orwater  craft,  which  is  infested  with  [rats,  mice,  gophers,  or  ground  squir- 
rels, or]  as  soon  as  the  presence  of  the  same  shall  come  to  his,  their,  or  its  knowledge, 
at  once  to  proceed  and  to  continue  in  good  faith  to  endeavor  to  exterminate  and 
destroy  such  rodents,  by  poisoning,  trapping,  and  other  appropriate  means. 

[Sec  2.]  The  state  board  of  health  and  inspectors  appointed  by  such  board,  and 
local  health  officers  and  inspectors  appointed  for  the  purpose,  as  hereinafter  provided, 
shall  have  authority,  and  shall  be  permitted  to  enter  into  and  upon  any  and  all  lands, 
places,  buildings,  structures,  wharves,  piers,  docks,  vessels,  and  water  craft,  for  the 
purpose  of  ascertaining  whether  the  same  are  infested  with  such  rodents  and  whether 
the  requirements  of  this  act  as  to  the  extermination  and  destruction  thereof  are  being 
complied  with;  provided,  however,  that  no  building  occupied  as  a  dwelling,  hotel,  or 
rooming  house,  shall  be  entered  for  such  purpose,  except  between  the  hours  of  nine 
o'clock  in  the  forenoon  and  five  o'clock  in  the  afternoon  of  any  day. 

[Sec  3.]  The  board  of  supervisors  of  each  county  and  the  city  council  or  other 
governing  body  of  each  city  and  county,  city  and  town,  whenever  it  may  by  resolution 
determine  that  it  is  necessary  for  the  preservation  of  the  public  health  or  to  prevent 
the  spread  of  contagious  or  infectious  disease,  communicable  to  mankind,  or  when 


174  HYGIENE 

such  board  shall  so  determine  that  it  is  necessary  to  prevent  great  and  irreparable 
damage  to  crops  or  other  property,  may  appropriate  moneys  for  the  purchase  of,  and 
may  purchase  poison,  traps,  and  other  materials  for  the  purpose  of  extermina-  ing  and 
destroying  such  rodents,  in  such  county,  city  and  county,  city  or  town,  and  may  employ 
and  pay  inspectors,  who  shall  have  authority  to  and  shall  prosecute  such  work  of  ex- 
termination and  destruction,  under  the  direction  of  such  board,  or  of  the  local  health 
officer,  or  board  of  health,  on  both  private  and  public  property,  in  such  county,  city 
and  county,  city  or  town. 

[Sec.  4.]  Whenever  any  person,  firm,  co-partnership,  company,  or  corporation, 
owning,  leasing,  occupying,  possessing  or  having  charge  of  or  dominion  over,  any  land, 
place,  building,  structure,  wharf,  pier,  dock,  vessel,  or  water  craft,  which  is  infested 
with  such  rodents,  shall  fail,  neglect,  or  refuse  to  proceed  and  to  continue  to  endeavor 
to  exterminate  and  destroy  such  rodents,  as  herein  required,  it  shall  be  the  duty  of  the 
state  board  of  health,  its  inspectors  and  the  local  board  of  health  and  health  officer,  at 
once  to  cause  such  nuisance  to  be  abated  by  exterminating  and  destroying  such 
rodents.  The  expense  thereof  shall  be  a  charge  against  the  county,  city  and  county, 
city  or  town,  wherein  the  work  is  done,  and  the  board  of  supervisors  or  other  governing 
body  shall  allow  and  pay  the  same.  Thereupon,  the  clerk  of  such  board  shall  file  in 
the  office  of  the  county  recorder  a  notice  of  such  payment,  claiming  a  lien  on  such 
property  for  the  amount  of  such  payment.  Any  and  all  sums  so  paid  by  such  county, 
city  and  county,  city  or  town,  shall  be  a  lien  on  the  property  on  which  said  nuisance 
shall  have  been  abated,  and  may  be  recovered  in  an  action  against  such  property, 
which  action  to  foreclose  such  lien  shall  be  brought,  within  ninety  days  after  such  pay- 
ment, and  be  prosecuted  by  the  district,  city  or  town  attorney,  in  the  name  of  such 
county,  city  and  county,  city  or  town,  and  for  its  benefit.  When  the  property  is  sold, 
enough  of  the  proceeds  shall  be  paid  into  the  treasury  of  such  county,  city  and  county, 
city  or  town,  to  satisfy  such  lien  and  the  costs,  and  the  overplus,  if  any  there  be,  shall 
be  paid  to  the  owner  of  the  property,  if  known,  and  if  not  known  shall  be  paid  into 
court  for  the  use  of  such  owner  when  ascertained.  When  it  appears  from  the  com- 
plaint in  such  action  that  the  property  on  which  such  liens  is  to  be  foreclosed  is  likely 
to  be  removed  from  the  jurisdiction  of  the  court,  the  court  may  appoint  a  receiver  to 
take  possession  of  the  property  and  hold  the  same  while  the  action  may  be  pending  or 
until  the  defendant  shall  execute  and  file  a  bond,  with  sufficient  suredes,  conditioned 
for  the  payment  of  any  judgment  that  may  be  recovered  against  him  in  the  action  and 
all  costs. 

[Sec.  5.]  Any  violation  of  the  provisions  of  this  act  shall  be  deemed  a  mis- 
demeanor and  shall  be  punishable  as  such. 

Canal  Zone 

By  direction  of  Col.  W.  C.  Gorgas,  U.  S.  A.,  chief  sanitary  officer,  with 
headquarters  at  Ancon,  C.  Z.,  a  most  interesting  package  of  documents  was 
sent  to  me.  It  seems  strange  for  the  United  States  to  have  sanitary  regula- 
tions printed  in  four  languages,  and  to  be  a  party  to  such  a  decree  as  is  the 
following : 

DECREE  NUMBER  33  OF  1905 

(Of  18th  February) 

Approving  Sanitary  Regulations 
The  President  of  the  Republic  of  Panama,  in  the  exercise  of  his  attributes,  and 

CONSIDERING 
That  in  accordance  with  Article  VII  of  the  Treaty  of  18th  November,  1903,  for 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  175 

the  opening  of  a  maritime  canal  across  the  isthmus,  the  United  States  of  America  are 
charged  with  the  regulation  of  the  sanitary  conditions  in  the  cities  of  Panama  and 
Colon;"  ....  etc.     Then  follow  the  decrees. 

Enacted  in  Panama  on  the  18th  day  of  February,  1905. 

(Sgd.)  M.  Amador  Guerrero 

The  secretary  of  government  and  foreign  relations, 

(Sgd.)  Santiago  de  la  Guardia. 

The  decrees  are  those  of  the  redoubtable  Colonel  Gorgas  and  would  make 
the  people  "  back  in  the  states  "  think  something  had  happened.  It  is  five 
dollars  (gold)  fine  to  breed  "  v^^igglers  "  on  your  property,  and  if  the  mayor 
does  not  impose  the  fine,  he  is  fined  from  five  to  one  hundred  gold  dollars.  All 
manner  of  sew^age  and  other  regulations  are  imposed  and  a  blanket  "  nui- 
sance "  section  reads: 

Whatever  is  dangerous  to  human  life  or  health,  whatever  building,  or  part  or 
cellar  thereof,  is  overcrowded  or  not  provided  with  adequate  means  of  ingress  and 
egress,  or  is  not  sufficiently  ventilated,  drained,  lighted  or  cleaned,  and  whatever  ren- 
ders soil,  air,  water,  or  food  impure  or  unwholesome,  are  declared  to  be  nuisances  and 
illegal. 

What  would  a  New  York  or  Chicago  lawyer  think  if  that  were  a  national 
law  and  imposed  upon  all  of  the  states  ?  In  Colon  and  Panama  even  a  phy- 
sician (to  say  nothing  of  a  clergyman)  may  not  visit  any  of  the  quarantined 
diseases,  except  chickenpox,  without  a  permit.  And  the  tropics  used  to  be 
considered  "  slow."  And  when  we  come  to  read  the  annual  reports,  we  see 
what  this  highly  specialized  system  does.  In  one  of  them  Colonel  Gorgas 
said :  "  The  working  efficiency  of  our  force,  as  far  as  loss  from  sickness  is  con- 
cerned, is  as  good  as  that  of  a  similar  force  anywhere  in  the  United  States, 
and  better  than  that  of  either  our  army  or  navy." 

For  details,  permit  me  to  refer  to  the  following  papers  by  Colonel 
Gorgas : 

"  Mosquito  Work  in  Havana."  Medical  Record,  July  10,  1902.  "  Sanitary 
Conditions,"  etc.,  in  Canal  Zone.  Medical  Record,  Feb.  4,  1905.  "  Sanitary  Work 
on  the  Isthmus,"  etc.  Med.  Record,  May  18,  1907.  "  Sanitation  of  the  Canal 
Zone."  Medical  Record,  Feb.  15,  1908.  "  Method  of  the  Spread  of  Yellow  Fever." 
Medical  Record,  June  27,  1908.  "  Destroying  Mosquitoes."  Washington,  Gov- 
ernment  Printing  Office,   1904. 

In  all  history  there  has  never  been  such  an  object  lesson  in  practical  sani- 
tation. Considering  the  former  conditions,  and  then  the  present  ones,  it 
makes  a  good  health  officer  dream  of  the  time  when  public  opinion  has  been 
trained  to  such  a  point  in  this  country  that  a  benevolent  government  will  be 
allowed  to  adequately  enforce  the  laws  necessary  to  make  our  own  record 
show  that  sin  and  filth  are  our  worst  enemies  and  that  we  can  do  even  better 
than  the  Canal  Zone.  The  good  old  Uncle  Samuel  makes  the  "  kids  "  obey 
but  allows  his  grown  children  to  do  much  as  they  please. 

Colorado 

The  state  board  of  health  of  this  state  has  offices  in  the  capitol  building  at 
Denver,  is  well  organized,  has  an  energetic  food  division,  does  laboratory 


176  HYGIENE 

work,  employs  capable  inspectors,  and  conducts  several  lines  of  work.  For 
eight  years  the  board  has  published  a  bulletin  containing  much  interesting 
data.  The  counties  are  duly  organized  and  the  vital  statistics  are  reported 
by  registrars.  The  work  is  effective,  but  is  along  the  same  lines  outlined  in 
the  work  of  others  of  the  states  of  the  mid-west  and  presents  few  points  of 
difference  requiring  description  in  detail. 

Connecticut 

The  business  of  the  state  board  of  health  is  transacted  from  the  office  of 
the  secretary  in  New  Haven.  The  statutes  of  the  state  bearing  upon  public 
health  and  safety  are  highly  elaborated  and  are  the  gradual  accretion  of  an  old 
state  with  varied  interests.  These  acts  extend  from  that  concerning  the 
"  secret  delivery  of  a  bastard,"  enacted  in  1808,  up  to  legislation  concerning 
osteopathy  of  recent  date;  and  they  embrace  everything  of  interest  to  health 
or  safety  in  between  these  dates. 

A  feature  that  commends  the  laws  of  Connecticut  is  that  they  seem  to  be 
especially  devised  to  protect  the  individual  citizen  more  than  to  regulate  every- 
thing under  the  sun  and  provide  salaries  for  politicians  to  do  what  local  author- 
ities would  do  better  than  some  hybrid  commission  or  half-cooked  "  expert." 

Another  good  thing  about  their  laws  is  that  they  are  not  drawn  in  the 
interest  of  the  brewers  and  distillers,  and  the  prescribing  of  and  adulteration 
of  liquors  is  fully  regulated.  This  state  does  not  forget  to  look  after  child 
labor  and  to  regulate  the  so-called  "  clubs  "  that  are  making  drunkards  of 
our  young  men  in  so  many  places.  In  other  words,  the  humanities  are  not 
forgotten  by  this  old  state.  I  do  not  mean  to  criticise  the  boards  in  younger 
states,  but  do  feel  that  some  of  them  would  do  well  to  remember  that  health 
demands  something  more  than  mere  material  science,  and  after  they  have 
developed  essentials,  make  a  study  of  the  legislation  of  states  whose  health 
departments  have  been  in  operation  long  enough  for  people  and  officials  to 
come  to  some  mutual  understanding  of  what  is  needed.  This  board  issues 
very  good  bulletins,  and  its  publications  give  one  an  excellent  impression  of 
their  work, 

Delaware 

The  state  board  of  health  has  offices  at  Wilmington  and  a  pathological 
and  bacteriological  laboratory  at  Delaware  College.  This  is  not  a  very  power- 
ful board,  the  law  making  the  organization  of  local  boards  obligatory  and 
giving  them  considerable  control  in  local  affairs.  However,  the  state  board 
exercises  a  general  supervision,  and,  in  case  of  local  neglect,  has  power  to  act. 
As  to  nuisances,  complaint  must  be  made  in  writing,  but  the  statutes  define 
nuisances  very  well  and  the  powers  of  relief  are  adequate.  Quarantine,  vital 
statistics,  water  supply  regulation,  etc,  are  provided  for  by  proper  laws. 

Twice  a  year  the  executive  officer  makes  a  tour  of  the  state  and  the  tone 
of  the  literature  issued  is  exceedingly  temperate  and  gives  one  the  impression 
that  the  officials  and  the  physicians  in  Delaware  are  working  in   harmony. 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  177 

The  legislature  appropriates  a  rather  small  sum  for  the  maintenance  of  the 
work,  but  provides  for  additional  sums  to  be  expended  in  case  of  serious 
epidemic. 

The  regulations  under  which  the  work  of  the  state  and  local  boards  are 
done  are  well  drawn  and  are  very  reasonable. 

District  of  Columbia 

The  commissioners  of  the  District  of  Columbia  have  charge  of  the  health 
work,  but  delegate  it  to  the  health  officer,  who  has  a  small  army  of  assistants 
under  him.  They  put  into  effect  as  elaborate  a  code  as  is  found  anywhere 
in  the  country.  The  district  regulations  are  also  those  of  the  city  of  Wash- 
ington, and  as  that  matter  is  discussed  and  the  regulations  given  in  some 
detail  under  the  heading  of  the  special  problem  of  cities  in  the  chapter  on 
local  boards  of  health,  it  is  unnecessary  to  repeat  the  data  here.  The  work 
is  almost  a  model  in  its  plan  and  works  out  well  in  practice. 

Florida 

The  revised  statutes  of  the  state  of  Florida  provide  adequate  regulations 
for  the  enforcement  of  rigid  quarantine  in  time  of  epidemic,  and  for  fairly 
detailed  conduct  of  all  matters  involved  in  sanitation.  The  state  board  of 
health  employs  a  medical  state  health  officer,  who  is  given  full  powers,  subject 
to  the  approval  of  the  board.  For  the  support  of  the  detailed  work  of  the 
board,  a  state  tax  of  one  half  mill  is  assessed  upon  the  property  of  the  state 
and  the  governor  is  authorized  to  expend  additional  sums  necessary  in  time 
of  epidemic. 

Railroads  and  vessels,  nuisances,  hotels  and  boarding  houses,  and  domes- 
tic animals  are  subjects  of  stringent  rules,  ever  keeping  in  mind  the  danger 
from  yellow  fever,  the  large  number  of  tourists  coming  into  the  state,  and  the 
danger  (in  a  warm  climate)  of  animal  infections. 

The  .State  Bureau  of  Vital  Statistics  conducts  its  work  under  very  good 
regulations,  and  the  part  of  the  practitioner  of  medicine  in  making  reports  for 
quarantine  and  statistics  is  fully  outlined  and  the  penalties  for  neglect  thereof 
may  be  made  quite  heavy. 

^s)  The  counties  are  fairly  well  organized  and  are  under  the  supervision  of 
the  state  board.  The  rules  and  regulations  are  very  rigid  as  regards  vacci- 
nation, shipping,  filth,  and  nuisances,  and  they  are  doubtless  very  necessary  in 
so  warm  a  climate. 

^  The  organization  is  not  a  very  large  one,  but  judging  from  its  printed 
regulations  it  is  fully  alive  to  its  responsibilities,  and  from  its  office  at  Jackson- 
ville keeps  a  very  tight  rein  upon  affairs  in  the  thickly  populated  portions  of 
the  state,  but  does  not  expect  so  much  from  the  weaker  counties. 

Georgia 

In  a  letter  from  Dr.  H.  F.  Harris,  secretary  of  the  Georgia  State  Board  of 
Health  and  director  of  the  laboratories,  it  appears  that  Georgia  is  beginning, 


178  HYGIENE 

in  a  veiy  scientific  way,  what  promises  to  be  a  splendid  work.     The  letter 
itself  best  gives  the  data.     It  is  as  follows : 

My  Dear  Doctor:  In  reply  to  your  letter  I  would  say  that  the  work  being  done 
by  our  state  board  of  health  is  almost  entirely  of  a  scientific  character.  We  have  a 
well-equipped  laboratory  where  examinations  are  made  for  bacteria  and  parasites 
that  produce  disease,  and  the  results  promptly  reported  to  the  physician  sending  the 
specimen,  all  of  which  is  free  of  cost. 

We  have  a  well-equipped  laboratory  for  the  Pasteur  preventive  treatment  of  rabies, 
—  there  having  been  treated  here  between  three  and  four  hundred  cases  during  the  last 
year;  if  the  patients  desire  it  or  are  too  poor  to  stand  the  expense  of  a  trip  to  this  city, 
the  virus  is  prepared  daily  and  forwarded  to  the  victim's  physician,  who  does  the  in- 
oculating. 

We  also  prepare  diphtheria  antitoxin, —  the  method  of  Gibson  for  concentrating 
the  same  being  employed.  ^-3 

We  also  make  tuberculins,  malleins,  etc.  All  of  this  is  furnished  free  of  cost  to  the 
patient. 

The  law  creating  our  board  directs  that  we  keep  a  record  of  vital  statistics,  but 
under  existing  conditions  this  is  utterly  out  of  the  question,  and  we  have  made  no 
attempt  to  comply  with  this  requirement.  At  best  such  figures  are  more  or  less 
unreliable,  and  where  no  local  boards  of  health  exist  no  real  idea  can  be  secured  as  to 
matters  of  this  kind.  Only  the  larger  cities  in  this  state  have  boards  of  health,  and  the 
counties  are  without  them  almost  without  exception. 

Very  cordially  yours, 

H.  F.  Harris, 

Secretary. 

The  difficulty  Dr.  Harris  notes  with  regard  to  vital  statistics  is  reflected 
in  the  correspondence  with  other  states.  From  my  own  observation,  a  divi- 
sion of  vital  statistics,  to  be  at  all  effective,  requires  dozens  of  clerks  and  is 
so  expensive  to  maintain  to  a  point  of  efficiency  that  it  is  hardly  justified  for 
a  state  to  expend  much  money  upon  such  work  if  in  doing  so  other  work  is 
curtailed.  If  the  finances  of  the  state  warrant  the  expenditure  of  sufficient 
money,  the  work  may  be  made  highly  useful. 

Guam 

The  following  is  an  editorial  cut  from  The  Journal  of  the  American 
Medical  Association  for  September  11,  1909.  It  is  a  statement  of  remarkable 
conditions  in  Guam: 

POSSIBILITIES  OF  MODERN  PREVENTIVE  MEDICINE 

It  has  been  asserted  that  if  the  knowledge  of  the  transmission  of  disease  which 
we  already  possess  could  be  fully  utilized  it  would  be  possible  —  without  the  dis- 
covery of  a  single  new  fact  —  to  increase  materially  the  average  span  of  human  life  and 
immeasurably  to  diminish  human  distress.  Sanitarians  have  often  longed  for  an 
opportunity  to  prove  the  truth  of  this  in  a  community  where  the  necessary  authority 
and  facilities  could  be  provided  and  thus  to  show  what  modern  preventive  medicine 
is  capable  of  accomplishing.  It  seems  that  in  the  Island  of  Guam  many  of  the  con- 
ditions of  such  a  medical  Utopia  can  be  found. 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  179 

This  island,  which  is  solely  a  naval  station,  has  a  native  population  of  11,636  and 
a  foreign  population  of  398,  about  one  half  of  which  is  made  up  of  the  naval  forces. 
The  government  is  a  sort  of  beneficent  autocracy  entirely  in  the  hands  of  naval  officers, 
and  all  affairs  relating  to  health  and  sanitation  are  administered  by  naval  medical  offi- 
cers. There  are  no  other  physicians  in  the  colony,  and  so  these  officers  are  charged 
with  the  care  of  the  sick.  Hospital  accommodations  are  ample  and,  by  means  of 
dressing  stations  and  clinics,  relief  is  extended  in  all  parts  of  the  island.  There  is 
provision  in  segregated  colonies  for  all  cases  of  leprosy  and  gangosa  and  a  small  sepa- 
rate hospital  for  other  communicable  diseases.  A  medical  officer  detailed  as  patho- 
logist of  the  station  is  engaged  in  investigating  the  nature  and  causes  of  the  diseases 
peculiar  to  Guam.  Such  a  rare  centralization  of  medical  research,  sanitary  admin- 
istration and  the  care  of  all  classes  of  the  sick  makes  conditions  almost  ideal  for  a  prac- 
tical demonstration  in  preventive  medicine.  The  fact  that  more  than  three  fourths  of 
the  native  population  of  the  island  is  concentrated  in  a  large  town  where  overcrowd- 
ing is  extreme  and  that  Guam  is  afflicted  with  the  usual  endemic  diseases  and  with 
general  worm  infection  simply  makes  the  results  of  the  experiment  of  so  much  more 
interest  and  value. 

In  the  July  issue  of  the  United  States  Naval  Medical  Bulletin  one  may  read  what 
has  been  accomplished  in  the  short  period  of  American  occupation.  The  reports  of 
the  medical  officers  for  1907  and  1908  are  full  of  interest  and  should  be  read  in  detail 
by  all  those  interested  in  tropical  sanitation,  but  the  results  of  the  splendid  work  which 
has  been  done  are  sufficiently  well  shown  by  the  death  rate  of  24.3  per  1,000.  Some 
idea  of  what  such  a  rate  means  in  the  tropics  may  be  gained  from  comparison  with 
the  mortality  in  tropical  cities  which  have  long  been  under  the  control  of  European 
governments,  and  from  the  fact  that  Guam's  death  rate  is  exceeded  in  not  a  few  cities 
in  the  United  States.  Twenty  per  cent  of  the  deaths  in  Guam  are  caused  by  guha,  an 
epidemic  respiratory  disease  peculiar  to  the  Ladrone  and  Caroline  Islands.  The 
death  rate  from  all  other  causes  was  19.9.  In  many  countries  in  Europe  such  a  rate 
as  this  would  be  considered  remarkably  low  at  the  present  time,  and  there  are  many 
communities  in  the  most  favored  parts  of  this  country  which  have  not  yet  been  able  to 
attain  it.  The  results  achieved  in  the  Canal  Zone  have  set  a  standard  for  tropical 
sanitation,  but  the  presence  there  of  a  large  temporary  population  within  an  age  period 
having  normally  a  very  low  death  rate  renders  comparison  with  other  tropical  com- 
munities less  significant  than  in  the  case  of  Guam, 

In  Guam  it  is  planned  to  replace  the  water  supply  by  means  of  wells  with  one  from 
an  uncontaminated  source  and  to  extend  the  sewer  system.  With  such  means  of  con- 
trolling infection  from  intestinal  parasites  it  is  likely  that  the  vital  statistics  of  this  in- 
significant Pacific  isle  will  assume  an  importance  li;tle  dreamed  of  by  those  who  under- 
took its  sanitation  as  part  of  the  day's  work. 

It  is  a  strange  commentary  on  our  progress  in  matters  relating  to  the  public  health 
that  we  must  go  to  the  edges  of  the  civilized  world  for  examples  of  what  can  be  done 
in  the  control  of  disease,  but  if  the  true  lesson  of  the  splendid  victories  which  have 
been  won  in  Guam,  the  Canal  Zone  and  our  other  tropical  possessions  is  ever  fully 
grasped  by  those  who  make  and  administer  the  laws  in  our  own  country  the  end  of  the 
present  sacrifice  of  human  lives  from  preventable  causes  will  be  in  sight, 

Hawaii 

The  work  is  under  the  supervision  of  the  United  States  Public  Health 
and  Marine  Hospital  Service,  Dr,  L.  E.  Gofer  in  charge.  It  is  outlined  in 
the  1908  Report  of  the  Surgeon  General  of  the  Service,  pages  117  to  124,  and 


180  HYGIENE 

is  done  in  the  thorough  manner  just  described  under  Guam,  and  as  indicated 
in  the  discussion  of  the  service  in  Chapter  XII. 

Idaho 

The  Idaho  State  Board  of  Health  has  an  officer  at  Boise.  The  health 
laws  are  brief,  but  provide  adequately  for  all  of  the  state  regulations  and  offi- 
cials necessary  for  reports  of  infectious  disease  and  vital  statistics.  Local 
boards  are  required  and  are  given  much  latitude  as  to  local  requirements.  A 
step  in  advance  of  some  other  and  older  boards  is  the  required  reporting  of 
ophthalmia  neonatorum.     A  note  in  large  type,  says : 

The  state  board  has  deemed  it  prudent  in  order  to  stamp  out  smallpox  which  is 
so  prevalent  in  our  midst,  to  insist  upon  as  strict  a  quarantine  of  chickenpox  as  of  the 
former  disease,  thereby  avoiding  the  confusion  heretofore  incident  to  the  difficulties 
of  diagnosis  between  chickenpox  and  varioloid. 

Illinois 

The  state  board  of  health  is  well  organized  and  with  the  office  and 
laboratcxy  at  Springfield.  There  is  an  executive  officer,  a  legal  department, 
a  department  of  vital  statistics,  a  water  surve}',  a  department  of  lodging  house 
inspection,  state  examiners  of  embalmers  and  a  laboratory  staff.  There  is  a 
state  food  commissioner  and  a  vigorous  prosecution  of  the  evils  of  bad 
dairies  and  adulterated  and  misbranded  food  is  in  progress.  The  board  of 
health  distributes  antitoxin  and  is  doing  practically  all  of  the  lines  of  work 
devolving  upon  a  state  board.  The  city  of  Chicago  has  such  an  efficient 
department  of  health  that  it  constitutes  an  aid  to  the  state  organization.        a^ 

The  circulars  issued  upon  the  various  contagious  diseases  are  among  the 
best  I  have  seen  and  cannot  fail  to  be  of  value,  and  the  one  upon  the  care  of 
the  baby  is  to  be  especially  commended.  The  Monthly  Bulletin  is  one  of  the 
best  issued  by  any  state.  The  issue  for  1908,  if  bound,  would  make  a  fair- 
sized  volume. 

Illinois  was  one  of  the  first  states  of  the  Union  to  establish  a  state  board 
of  health,  and  it  is  a  rather  powerful  board.  While  the  law  under  which  it 
operates  is  not  very  specific,  yet  it  is  sweeping  in  the  latitude  given  under  the 
"  police  power." 

The  board  is  making  an  energetic  fight  against  tuberculosis. 

Indiana 

In  Chapter  XI  the  basis  of  the  Indiana  work  is  discussed  and  the  remarks 
there  made  may  be  of  interest  in  connection  with  what  is  here  said.  One 
only  needs  to  go  through  the  literature  issued  by  the  State  Board  of  Health  at 
Indianapolis,  to  see  that  the  state  is  to  be  congratulated  upon  its  efficient  work. 
The  laws  are  so  detailed  that  space  precludes  a  full  discussion  and  probably 
the  best  I  can  do  is  to  quote  from  a  letter  written  to  me  by  the  secretary  of 
the  board: 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  181 

Your  letter  received.  In  this  mail  we  send  you  a  copy  of  our  Book  of  Instruc- 
tions to  Health  Officers,  also  one  of  our  envelope  packages,  which  illustrates  somewhat 
the  work  we  are  doing.  We  now  have  a  new  health  law  which  wi.l  take  the  place  of 
the  one  you  will  find  printed  on  page  59.  It  will  not  go  into  effect  until  May  and  we 
cannot  furnish  you  a  copy  of  it  at  the  present  time.  The  vital  statistics  law  on  page  64 
and  the  Quarantine  Law  on  page  67,  are  still  in  force.  The  Pure  Food  Law  also  is 
enforced  by  the  state  board  of  health.  It  has  a  special  department  for  this  work,  with 
ample  laboratories,  fully  equipped.  With  the  package  find  a  copy  of  our  Pure  Food 
Law  and  the  rules  of  the  state  board  of  health. 

The  legislature,  just  adjourned,  passed  an  anti-stream  pollution  law,  enforcement 
of  which  depends  upon  the  state  board  of  health.  It  also  passed  a  law  concerning  the 
sanitation  of  food-producing  establishmenf;,  a  copy  of  which  is  enclosed.  Another 
law  requires  the  testing  of  cattle  with  tuberculine,  and  provides  for  the  paying  for  of  all 
cattle  tested,  found  not  to  be  diseased,  if  slaughtered. 

The  state  board  of  health  constantly  carries  on  a  campaign  of  education  in 
Hygiene  and  Sanitary  Science.  This  is  done  through  the  distribution  of  circulars, 
correspondence,  press  articles,  and  visits  to  cities.  Our  Tuberculosis  Exhibit  is  con- 
stantly traveling  over  the  state.  Illustrated  lectures  upon  the  "  Cure  and  Prevention 
of  Tuberculosis,"  and  also  upon  the  prevention  of  other  diseases.  We  have  two  lec- 
turers connected  with  the  board.  '■' 

A  good  hygienic  work  which  is  being  done  in  this  state  is  carried  on  by  the  Indiana 
Social  Hygiene  Society.  It  has  a  special  lecturer  who  appears  wherever  called  for, 
and  talks  upon  the  sexual  plagues.  The  society  also  distributes  literature.  You  will 
find  a  copy  of  the  pamphlet  which  they  dis.:ribute,  which  is  published  by  the  Indiana 
State  Board  of  Health,  in  the  envelope  package  which  is  sent  to  you. 

Very  truly  yours, 

J.    N.    HURTY, 

Secretary. 

The  Book  of  Instructions  to  Health  Officers  impresses  me  as  the  best 
pamphlet  of  its  sort  that  has  come  to  my  notice,  and  I  wish  to  call  attention 
to  the  model  city  and  tov^n  health  ordinances  recommended  in  this  pamphlet. 
If  the  Indiana  Board  had  never  done  anything  else,  it  could  still  be  com- 
mended for  issuing  the  health  circular  entitled  "  Social  Hygiene  vs.  The 
Sexual  Plagues."  This  is  far  and  away  the  very  best  little  book  upon  the 
subject  I  have  ever  read  and  is  referred  to  in  detail  elsewhere  in  this  book. 

Indian  Territory 
(See  Oklahoma) 

Iowa 

The  state  board  of  health  is  located  at  Des  Moines  and  is  organized  upon 
a  strict  legal  basis  of  administration,  its  orders  having  the  effect  of  law. 
Local  boards  are  held  strictly  to  account  by  it  and  must  organize  and  per- 
form their  duties.  The  regulations  provide  full  quarantine  protection,  and 
tuberculous  persons  are  excluded  from  many  occupations.  The  regulations, 
if  obeyed  to  the  letter,  could  be  made  pretty  harsh  upon  the  private  physician. 

The  directions  given  for  disinfection  and  the  care  of  infectious  diseases 
are  admirable  and  the  statutes  regulating  water  supply  are  to  be  commended. 

Iowa  is  one  of  a  small  group  of  states  to  place  under  the  state  board  of 
health  the  inspection  of  illuminating  and  miner's  oil. 


182  HYGIENE 

The  state  veterinarian  co-operates  with  the  United  States  Bureau  of 
Animal  Industry  and  so  far  as  I  am  capable  of  judging  the  matter,  the  regu- 
lations under  which  he  works  are  among  the  best  in  the  countr}. 

The  board  has  charge  of  the  examination  and  licensure  of  physicians, 
nurses,  embalmers,  osteopaths,  etc. 

The  board  wisely  employs  a  civil  engineer,  a  chemist,  and  a  force  of 
workers  in  the  state  laboratory. 

The  state  board  of  medical  examiners  have  laid  down  a  schedule  of 
minimum  requirements  for  the  equipment  of  a  medical  college  and  it  impresses 
me  as  a  step  in  the  right  direction. 

Kansas 

At  Topeka  the  state  board  of  health  has  its  office.  There  are  ten  mem- 
bers, inclusive  of  the  president,  the  secretary,  and  editor.  An  advisory 
board  consists  of  an  engineer,  a  skilled  sanitarian,  a  food  analyst,  a  drug 
analyst,  a  bacteriologist,  and  a  statistician.  The  scientific  work  is  done 
at  the  State  University,  at  Lawrence,  and  at  the  Agricultural  College,  at 
Manhattan. 

The  law  creating  the  board  is  adequate  for  the  conduct  of  an  effective 
service,  although  not  very  extended.  Quarantine,  vital  statistics,  and  sani- 
tary service  are  duly  provided.  County  boards  are  composed  of  the  county 
commissioners  and  a  physician  appointed  by  them. 

The  rules  and  regulations  of  the  board  are  quite  stringent  and  cover  a 
wide  field.  As  instances:  stagnant  ponds  are  not  allowed  in  the  state,  de- 
leterious substances  from  factories  may  not  be  discharged  into  any  stream, 
stables  are  fully  regulated,  school  vaccination  is  absolute,  cases  of  gonorrhoea 
are  regulated  to  some  extent,  and  no  person  with  syphilis  may  be  served  in  a 
barbershop. 

Free  and  extended  laboratory  service  is  rendered  to  physicans  and 
health  officers,  research  work  and  tests  of  food  and  drug  products  are  carried 
out,  and  a  steady  war  is  waged  against  tuberculosis. 

The  board  publishes  a  good  monthly  bulletin. 

Kentucky 

"  We  want  a  league,  offensive  and  defensive,  with  every  wellwisher  of 
Kentucky  and  her  people,"  is  the  motto  of  this  active  and  well-organized 
board.     The  executive  office  is  at  Bowling  Green. 

The  law  creating  the  state  and  local  boards  of  health  is  well  drawn,  and 
provides  for  the  usual  lines  of  work  in  a  very  harmonious  and  reasonable 
way  as  regards  others  interested,  but  there  are  two  features  that  merit  atten- 
tion. First,  the  common  carriers  and  other  corporations  are  more  fully 
regulated  than  is  the  case  in  most  of  the  Southern  states;  second,  the  laws  are 
enforced.  As  evidence  of  this,  it  is  interesting  to  read  over  the  court  decisions 
affirming  the  legality  of  the  regulations.  Health  officers  lacking  judicial  pre- 
cedents should  write  to  Dr.  J.  N.  McCormack,  of  Bowling  Green,  for  a  copy 
of  the  Kentucky  decisions.     It  is  to  be  feared  that  very  prolix  laws  and  regu- 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  183 

lations  lead  to  more  or  less  laxity  as  regards  enforcement,  and  the  shorter 
codes  of  the  states  actively  enforcing  them  are  to  be  preferred. 

The  Kentucky  Board  issues  an  excellent  series  of  bulletins  upon  the  pre- 
vention of  disease,  including  one  upon  ophthalmia  neonatorum,  and  from  it  I 
quote  the  following: 

As  soon  as  the  child  is  born  the  eyes  should  be  carefully  cleansed  with  a  saturated 
solution  of  boracic  acid,  wiped  dry  with  a  little  absorbent  cotton,  the  lids  carefully 
opened  and  one  or  two  drops  of  a  two  per  cent  solution  of  nitrate  of  silver  dropped 
into  the  conjunctival  sac.  This  application  should  neither  be  neutralized  with  a 
salt  solution  nor  be  repeated. 

Louisiana 

One  of  the  most  elaborate  and  interesting  reports  that  have  come  into 
my  hands  is  the  last  biennial  report  of  the  Louisiana  State  Board  of  Health. 
The  m.ere  fact  that  the  index  to  the  report  takes  sixty-one  closely  printed 
pages  is  enough  for  one  to  realize  that  it  v^ould  take  a  long  article  to  detail 
all  of  the  activities  of  this  busy  board.  Suffice  it  to  say  that  nearly  every  line 
of  sanitation  is  undertaken  and  that  the  matter  of  mosquito  control  is  more 
fully  developed  than  anywhere  else  in  the  United  States. 

The  board  has  a  big  project  on  hand,  as  any  one  can  see  by  a  visit  to  this 
gulf  coast  state.  Large  tracts  of  the  state  are  populated  by  colored  people 
who  are  hard  to  educate  up  to  the  standard  in  hygiene,  and  the  energetic 
campaign  of  education  is  very  necessary.  There  is  a  close  co-operation  be- 
tween the  board  and  the  physicians  of  the  state.  Maritime  quarantine  and 
the  contact  with  the  republics  of  South  and  Central  America  make  it  necessary 
for  the  board  to  be  very  closely  identified  with  the  Public  Health  and  Marine 
Hospital  Service  of  the  federal  government. 

Louisiana  maintains  excellent  laboratories,  and  is  undertaking  a  most 
energetic  campaign  against  impure  and  adulterated  food  and  drugs.  Few 
states  in  the  Union  have  so  full  a  code  of  regulations  governing  this  important 
matter. 

Permit  me  to  call  attention  to  the  excellent  financial  management  of  the 
affairs  of  this  board.  There  are  some  first-class  men  paid  fair  salaries,  but 
I  do  not  know  of  another  state  that  can  show  so  much  actual  work  done  per 
dollar.  At  all  events,  there  are  very  few  states  to  equal  the  record.  The 
work  of  this  board  is  referred  to  in  other  chapters  of  this  book.  The  offices 
are  in  New  Orleans. 

Maine 

The  state  board  of  health  has  its  office  at  Augusta  and,  judging  from  its 
voluminous  literature,  is  doing  an  effective  work  under  rather  inadequate  laws. 
The  1909  Legislature  is  adding  to  these  statutes  and  the  board  expects  its  posi- 
tion to  be  very  much  strengthened  thereby.  However,  the  laws  as  they  have 
been  provide  very  well  for  the  organization  of  local  boards  and  for  adequate 
quarantine,  etc. 

The  State  Laboratory  of  Hygiene  provides  good  diagnostic  facilities  and 
conducts  several  lines  of  work.     The  Maine  Sanatorium  is  doing  effective 


184  HYGIENE 

tuberculosis  work,  and  the  state  is  aroused  by  numerous  publications  upon 
tuberculosis.  The  bulletin  of  the  board  has  devoted  three  full  issues  to  this 
important  work. 

The  circulars  upon  the  several  infectious  diseases  issued  by  this  board 
are  most  excellent,  one  especially  instructive  being  upon  tuberculosis  in  cattle 
and  another  valuable  one  upon  infant  feeding. 

The  new  legislation  aims  to  make  persons  infected  with  tuberculosis  take 
proper  precautions  to  prevent  the  infection  of  others;  to  provide  free  anti- 
toxin in  diphtheria;  to  provide  for  the  support  of  families  under  quarantine 
and  to  add  to  existing  regulations. 

The  earnest  literature  of  the  board  impresses  the  reader  that  the  old  state 
of  Maine  is  not  behindhand  in  the  work  of  public  sanitation. 

Maryland 

The  business  of  the  state  board  of  health  is  transacted  from  the  office  of 
the  secretary,  8  and  10  South  Street,  Baltimore.  The  annual  reports  of  the 
board  are  interesting  to  those  devoting  attention  to  vital  statistics,  since  they 
are  very  complete  in  this  regard.  Any  one  who  has  been  much  in  the  state  of 
Maryland  cannot  but  be  impressed  with  the  large  number  of  charitable 
institutions  and  the  insanitary  conditions  prevailing  in  some  of  the  munici- 
palities. Both  of  these  factors  give  the  board  a  lot  of  work  to  do.  The  laws 
under  which  they  operate,  aside  from  provision  for  the  usual  matters  of  public 
hygiene,  designate  several  kinds  of  laboratory  work,  a  vaccine  agency,  rules 
against  sweatshops,  the  suppression  of  opium  traffic,  the  hours  of  labor  for 
children,  as  well  as  other  regulations  concerning  minors,  vagrants,  and  tramps 
under  regulation,  the  care  of  inebriates  and  other  things  showing  the  large- 
heartedness  of  the  Southern  people.  The  geography  of  the  state  is  such  as  to 
cut  it  into  two  parts,  and  there  are  so  many  bays  and  estuaries  with  sewage 
carried  back  and  forth  by  tidal  influences  or  sluggish  flow  that  the  sanitary 
problems  are  immense.  However,  the  laws  cover  about  all  of  the  several 
lines  of  sanitation  and  inspection,  but  county  and  smaller  town  reports  show 
that  the  board  must  overcome  much  local  inertia  in  order  to  be  effective  in 
some  districts.  By  a  comparison  with  conditions  I  noted  some  years  ago  they 
are  doing  well. 

The  more  recently  enacted  laws  include  a  very  rigid  vaccination  act  which 
practically  amounts  to  compulsory  vaccination,  new  pure  food  requirements, 
strengthening  the  local  boards,  providing  for  the  registration  of  tuberculosis 
etc,  A  novel  and  really  impressive  plan  of  treating  the  danger  from  tuber- 
culosis takes  the  attending  physician  into  the  state  service  as  provided  in 
Section  III  of  the  act,  as  here  quoted : 

Section  III.  It  shall  be  the  duty  of  the  local  board  of  health  to  transmit  to 
the  physician  reporting  any  case  of  pulmonary  or  larv'ngeal  tuberculosis  a  printed 
report  after  the  manner  and  form  to  be  prepared  and  authorized  by  the  state  board  of 
health  naming  such  procedures  and  precautions  as  in  the  opinion  of  the  state  board  of 
health  are  necessary  or  desirable  to  be  taken  on  the  premises  of  the  said  tuberculous 
case,  and  it  shall  be  the  duty  of  the  state  board  of  health  to  print  and  keep  on  hand 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  185 

sufficient  number  of  such  report  blanks  and  to  furnish  the  same  in  sufficient  number  to 
any  local  board  of  health  upon  due  requisition  of  the  latter.  Upon  receipt  of  the  blank 
report  the  physician  shall  fill,  sign,  and  date  the  same  and  return  to  the  local  board  of 
health  without  delay,  provided  that  if  the  attending  physician  is  unwilling  or  unable  to 
undertake  the  procedure  and  precautions  specified  he  shall  so  state  upon  his  report 
blank,  the  duties  herein  prescribed  shall  then  devolve  upon  the  local  board  of  health. 
Upon  receipt  of  this  report  the  local  board  of  health  shall  carefully  examine  the  same, 
and  if  satisfied  that  the  attending  physician  shall  have  taken  all  necessary  and  desirable 
precautions  to  insure  the  safety  of  all  persons  living  in  the  house  or  apartments  occupied 
by  the  consumptive  and  to  insure  the  safety  of  the  people  of  the  state  of  Maryland,  the 
said  local  board  of  health  shall  issue  an  order  on  the  state  board  of  health  in  favor  of 
the  attending  physician  for  the  sum  of  one  dollar  and  fifry  cents  ($1.50)  to  be  paid  by 
the  state  board  of  health  out  of  a  fund  hereinafter  provided.  If  the  precautions  taken 
by  the  attending  physician  are  in  the  opinion  of  the  local  board  of  health  not  such  as 
will  remove  all  reasonable  danger  or  probability  of  danger  to  the  persons  occupying  the 
said  house  or  apartment  the  local  board  of  health  shall  return  to  the  attending  physician 
the  report  blank  with  a  letter  specifying  the  additional  precautions  which  they  shall 
require  him  to  take,  and  the  said  attending  physician  shall  immediately  take  the  addi- 
tional precautions  specified  and  shall  record  and  return  the  same  on  the  original  blank 
to  the  local  board  of  health.  It  shall  further  be  the  duty  of  the  local  board  of  health  to 
transmit  to  the  physician  reporting  any  case  of  pulmonary  or  laryngeal  tuberculosis  a 
printed  requisition  which  shall  be  prepared  by  the  state  board  of  health  and  issued  in 
sufficient  number  to  any  local  board  of  heahh  upon  due  requisition  of  the  latter.  Upon 
this  requisition  blank  shall  be  named  the  materials  kept  on  hand  by  the  local  board  of 
health  for  the  prevention  of  the  spread  of  the  disease,  and  it  shall  be  the  duty  of  the 
state  board  of  health  to  purchase  such  supplies  as  it  may  deem  necessary  from  the  fund 
hereinafter  provided,  and  to  supply  them  to  any  local  board  of  health  upon  the  requi- 
sition of  the  latter.  Any  physician  may  return  a  duly  signed  requisition  to  the  local 
board  of  health  for  such  of  the  specified  materials  and  in  such  amount  as  he  may  deem 
necessary  in  preventing  the  spread  of  the  disease,  and  all  local  boards  of  health  shall 
honor  as  far  as  possible  a  requisition  signed  by  the  attending  physician  in  such  case. 
It  shall  be  the  duty  of  every  local  board  of  health  to  transmit  to  every  physician  report- 
ing any  case  of  pulmonary  or  laryngeal  tuberculosis  or  to  the  persons  reported  as 
suffering  from  this  disease,  provided  the  latter  have  no  attending  physician,  a  circular 
of  information  prepared  and  printed  by  the  state  board  of  health  and  which  shall  be 
furnished  in  sufficient  quantity  to  every  local  board  of  health  on  due  requisition  of  the 
latter.  This  circular  of  information  shall  inform  the  consumptive  of  the  best  methods 
of  cure  of  his  disease  and  of  the  precautions  necessary  to  avoid  transmitting  the  dis- 
ease to  others. 

The  importance  of  this  plan  is  such  that  we  reproduce  portions  of  the 
letter  and  blank  sent  to  the  attending  physician,  the  latter  to  be  filled  by  him. 
As  will  be  observed,  this  plan  preserves  inviolate  the  secrets  of  the  family, 
places  the  family  physician  in  charge  of  what  a  health  officer  usually  does,  and 
pays  the  physician  $1.50  for  his  trouble.  It  seems  to  me  to  be  an  effective 
step  toward  taking  the  family  doctor  into  partnership  with  the  state. 

Dear  Doctor: 

Acknowledging  and  thanking  you  for  your  report  just  received  ( 

)  we  hand  you  herewivh  an  inspection  blank.  Assuming  that  you  are 
attending  this  patient  we  ask  you  that  you  will  obtain  a  package  of  the  prophylactic 
supplies  which  the  state  furnishes,  take  it  with  you  to  the  house,  instruct  the  patient 


186  HYGIENE 

and  at  least  one  responsible  member  of  the  household  in  the  use  of  the  supplies  and  give 
such  instruccions  as  the  report  blank  suggests  with  such  other  advice  as  your  own 
judgment  approves.  Return  to  us  a  complete  report  of  your  observations  and  the 
instructions  which  you  have  given,  and  for  the  service  we  will  pay  ;^1.S0. 

Physicians  living  in  Baltimore  can  obtain  supplies,  in  person  or  by  an  author- 
ized messenger,  at  the  office  of  the  state  board  of  health  on  any  week  day  between  the 
hours  of  nine  and  four. 

Physicians  living  outside  Baltimore  will  be  supplied  by  the  health  officer  for  the 
county,  town,  or  district. 

Supplies  will  not  be  issued  for  any  unregistered  case. 

Very  truly  yours, 

Secretary. 

N.B. —  Money  appropriated  by  the  state  for  the  restriction  of  tuberculosis  cannot 
be  properly  expended  for  non-infectious  cases. 

The  sputum  must  be  examined  and  must  show  the  presence  of  tubercle  bacilli. 

N.B. —  There  are  three  places  on  the  blank  where  your  name  must  appear,  all 
on  the  fourth  page.  Sign  your  name  to  Part  III,  the  requisition  for  supplies.  Write 
your  name  twice  where  the  abbreviation  Dr.  occurs  under  the  headline  Endorsements. 

N.  B. —  Physicians  are  expected  to  perform  these  services  in  their  private  char- 
acter as  family  advisers,  and  to  avoid  unnecessary  show  of  official  intervention.  This 
does  not  mean  that  individuals  are  at  liberty  to  disregard  the  advice  of  the  physician. 

STATE  BOARD  OF  HEALTH  OF  MARYLAND 

State  of  Maryland,  County  of ,  Town  of 

REPORT  UPON  A  CASE  OF  TUBERCULOSIS 
Part  I 

Name  of  patient 

Address :    Town Maryland 

Age  of  patient years, months. 

Male  or  female  ? Married,  single,  or  widowed  ? 

White  or  colored  ? Birthplace  ? 

Birthplace  of  father  ? Birthplace  of  mother  .? 

Occupation 

Underline  the  definite  occupation  in  which  the  patient  is  engaged.  In  returning 
the  occupation  of  a  man,  do  not  use  such  indefinite  terms  as  "  laborer,"  "  tailor," 
"  mill  hand,"  "  carpenter,"  "  painter."  If  an  unskilled  laborer,  state  accurately  the 
sort  of  labor  usually  performed.  The  United  States  Census  recognizes  four  separate 
classes  of  carpenters,  eleven  classes  of  tailors,  four  classes  of  painters,  and  it  is  necessary 
for  us  to  conform  to  such  a  standard. 

In  returning  the  occupations  of  women,  it  should  be  noted  that  tuberculous  women 
abandon  their  occupations  much  earlier  than  men.  Specify  the  occupation  of  a  woman 
at  the  time  the  disease  became  apparent.  The  term  "  housework  "  should  not  be  used, 
as  it  includes  several  distinct  occupations,  namely,  housewives  (and  other  unpaid  mem- 
bers of  the  family),  housekeepers  (salaried),  domestic  servants  on  wages  (cooks, 
laundresses,  waitresses,  nurses,  chambermaids,  ladies'  maids,  etc.)  Always  make  a 
distinction  between  gainful  and  unpaid  occupations.  A  space  is  left  after  occupation 
for  the  return  of  unpaid  occupations,  such  as  housewives,  students,  school  children,  etc. 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  187 

Is  the  patient  now  engaged  in  the  original  occupation  ? 

Is  the  earning  power  as  good  as  ever  ? 

If  working  irregularly  or  at  reduced  wages,  how  long  ? 

If  totally  unable  to  work,  how  long  ? 

If  totally  disabled,  is  the  patient  confined  to  bed  ? 

If  there  has  been  consumption  in  the  family  history,  mark  in  the  list  below  those 
who  were  affected. 

Brother                            Father's  mother         Sister                            Mother's  mother 
Father                              Husband                      Mother                        Wife 
Father's  father               Son                               Mother's  father          Daughter 
Other  cases  in  the  house  now  or  formerly  ? 

If  the  patient  has  had  children,  how  many  are  living  ? Dead  .? 

Are  there  infants  or  young  children  in  the  house  ? 

If  the  patien^  is  a  mother,  does  she  nurse  an  infant  ? 

Does  the  patient  habitually  kiss  other  persons  on  the  mouth  ? 

Does  the  patient  use  dishes,  tableware,  pipes,  clothing,  handkerchiefs,  or  towels  in 

common  with  other  persons  ? 

Does  the  patient  prepare  the  food  of  the  family  ? 

DISPOSAL  OF  SPUTUM 

Does  the  patient  spit  upon  ihe  floor,  walls,  hearth,  or  furniture  ? 

Does  the  patient  spit  into  a  spitioon  used  by  other  persons  .? 

Does  patient  spit  into  a  handkerchief.? Does  patient  spit  into  a  paper 

napkin  ? 

Does  patient,  spit  into  a  paper  sputum  cup  .'' 

Into  a  china,  glass,  or  metal  sputum  cup  ? 

Is  water,  or  carbolic  acid,  or  any  disinfectant  used  in  the  sputum  cup  ? 

FINAL  DISPOSAL  OF  SPUTUM 

Is  the  sputum  burned  .? Is  it  thrown  into  a  water  closet  or  into  a  sewer  } .  .  . 

Is  it  thrown  upon  the  ground,  or  ini.o  surface  drain  or  gutter  ? 

Is  it  thrown  away  with  garbage,  ashes,  or  other  refuse  .'' 

Are  patient's  handkerchiefs  put  in  wash  with  other  clothing  .? 

Are  patient's  handkerchiefs  disinfected  before  being  laundered  } 

CONDITION  OF  THE  ROOM 

Is  the  room  suitable  in  size,  ventilation  and  lighting  for  a  tuberculous  person  ? 

Are  the  hangings,  floor  coverings  and  furniture  such  as  admit  of  proper  prophylaxis  L  . 
How  are  the  walls  finished   (rough  plaster,  smooth  plaster,  wainscoted,  papered, 

painted)  .? 

Are  the  walls  and  furniture  ever  wiped  off  with  a  disinfectant  solution  ? 

Is  the  room  swept  and  dusted  in  the  ordinary  way  with  broom  and  feather  duster  ?.  .  .  . 

Are  the  floors  ever  washed  with  a  disinfectant } 

How  many  other  persons  occupy  the  patient's  bedroom  ? 

Does  any  one  share  the  patient's  bed  ? 

Is  the  patient's  bedroom  used  as  a  kitchen  .? As  a  dining  room  ? 

Do  children  play  on  the  floor  of  the  bedroom  .'' 

Do  you  find  any  other  conditions  which  in  your  opinion  may  be  sources  of  danger  to 

those  on  the  premises,  or  to  the  public  ? 

In  order  to  expend  state  funds  for  tuberculosis  the  tubercle  bacillus  mus.  be  found. 
This  sheet  should  not  be  filled  until  the  bacillus  has  been  found  and  the  supplies  re- 
ceived and  their  use  demonstrated. 


188  HYGIENE 

PART  II 
(To  be  filled  afiier  supplies  have  been  received  on  requisition) 

PRECAUTIONS  TAKEN  AND  ORDERED 

Is  the  room  in  such  a  condition  as  to  require  formaldehyde  fumigation  before  other 
prophylactic  steps  are  taken  ? 

Have  you  delivered  the  supplies  received  upon  the  above  requisition  and  demonstrated 
their  use  ? 

If  the  patient  has  an  infant,  have  you  advised  her  of  the  danger  of  nursing  it  ? 

Have  you  advised  the  patient  not  to  kiss  any  one  on  the  mouth  ? 

Have  you  instructed  the  patient  when  coughing  to  hold  a  handkerchief  or  napkin 
before  the  face  ? 

Have  you  ordered  that  the  patient  shall  have  for  exclusive  personal  use  all  utensils  and 
articles  vphich  come  into  contact  with  the  mouth  ? 

Have  you  forbidden  the  use  by  others  of  the  patient's  utensils  or  wearing  apparel  ? 

Have  you  ordered  the  disinfection  of  wash  clothing  before  being  laundered  ? 

If  the  patient  prepares  or  handles  food  for  the  family,  have  you  given  careful  instruc- 
tions how  to  avoid  contaminating  the  food  ? 

Have  you  instructed  the  patient  to  carefully  avoid  contaminating  the  hands  and  to 
wash  and  disinfect  them  frequently,  especially  when  performing  any  household 
duty  ? 

Haf  e  you  instructed  the  patient  and  at  least  one  other  responsible  member  of  the  house- 
hold concerning  the  disinfection  of  hands,  utensils,  and  the  accidental  contamina- 
tion of  surroundings  ? 

Have  you  ordered  every  accidental  contamination  with  sputum  to  be  disinfected 
immediately  ? 

Have  you  forbidden  expectoration  anywhere  except  into  proper  receptacles  ? 

Have  you  ordered  the  sputum  cups  burned  after  use  not  exceeding  forty-eight  hours  ?.  . 

Have  you  directed  the  use  of  paper  napkins  and  waterproof  pocket  when  the  patient 
is  away  from  home  ? 

Have  you  ordered  the  paper  napkins  burned  daily  ? 

Have  you  forbidden  the  throwing  of  sputum  upon  the  ground,  or  in  surface  drains  or 
gutters  ? 

Have  you  forbidden  throwing  sputum  away  with  garbage,  ashes,  or  refuse  ? 

Do  the  patient's  circumstances  admit  of  special  furnishings  and  arrangement  of 
room  ? 

If  so,  have  you  made  any  of  the  following  recommendations: 

Removal  of  heavy  curtains  ? Use  of  sash  curtains  or  other  curtains  of 

wash  material  ? 

Removal  of  carpets  ? Useof  rugs,  preferably  of  cotton  or  other  washable 

material  ? 

Removal  of  large  and  unnecessary  pieces  of  furniture,  especially  such  as  inter- 
fere with  thorough  cleansing  of  the  room  ? 

Have  you  ordered  the  walls,  floors,  and  furniture  wiped  oflF  once  a  week  with  a  cloth 
wet  with  disinfecting  solution  ? 

Have  you  forbidden  dry  sweeping  and  dusting  in  the  patient's  room  ? 

Have  you  advised  against  the  patient's  sleeping  with  any  other  person  ? 

Is  it  practicable  to  have  no  other  person  to  sleep  in  the  room  ? 

Have  you  advised  against  preparing  or  serving  food  in  the  patient's  room  ? 

Have  you  advised  that  children  should  not  be  allowed  to  play  on  the  floor  of  the 
patient's  room  ? 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH 


189 


PART  HI 

Requisition  for  Supplies 

I  hereby  make  application  for  the  following  supplies  to  be  used  in  preventing  the 

spread  of  tuberculosis  on  the  premises  of ,  a  consumptive. 

75  Sputum  Cups. 

1  lb.  of  Liquid  Disinfectant. 

2  Waterproof  Bags. 

200  Japanese  Paper  Napkins. 
1  Cup  Holder. 

(Signed) M.D. 

Note.     Supplies  will  not  be  issued  for  more  than  three  months.     The  above  list  in- 
cludes all  the  supplies  which  can  be  issued  to  one  patient  at  one  time. 


ENDORSEMENTS 


(^1.50)  has  been  issued  upon  the  state 
board  of  health. 


1.  The  requisition  for  supplies  made  by 

Dr 

OF  Secretary  or  Executive  Board  of  Health 

of    •••;•. •• 

is   approved,   and   the   same   have   been  3.     I  am  unwilling  or  unable  to  take  the 

issued.  precautions  specified  in  this  circular  and 

hereby  turn  the  case  over  to  the  board  of 
health  for  its  action. 

Secretary  or  Executive  Board  of  Health 

M.D. 

of Attending  Physician 

2.  The  precautions  taken  and  ordered 

by  Dr Note. — The  last  endorsemen;  is  only 

OF  made  by  the  attending  physician  when  he 
is  unable  or  unwilling  to  provide  for  the 

- safety  of  those  occupying  the  premises 

have  been  sufficient  to  insure  the  safety  of  with  the   consumptive.     When   this   en- 

every  one  occupying  the  premises  men-  dorsement  is  made  by  the  physician  all 

tioned  in  this  report,  and  are  approved,  of  his  duties  devolve  upon  the  local  board 

and  an  order  for  one  dollar  and  fifty  cents  of  health. 

INSTRUCTIONS  TO  THE  TOWN  OR  COUNTY  BOARD  OF  HEALTH 


1.  The  law  requires  all  details  of  information  concerning  cases  of  tuberculosis  to 

be  held  confidential.  No  matter  how  fully  the  general  public  may  be  informed 
concerning  any  case,  official  discussion  must  be  confined  to  the  local  health  officer, 
the  state  board  of  health,  the  attending  physician,  and  the  infected  household. 

2.  As  soon  as  the  name  of  the  attending  physician  is  received,  you  will  forward  to  him 
the  four-page  circular  issued  to  you  with  instructions  to  fill  Part  I,  and  the  blank 
requisition  for  supplies  (Part  III).  When  the  circular  is  returned  to  you  properly 
executed,  you  will  return  it  to  the  attending  physician  with  one  quarter's  supply 
of  prophylactic  material,  and  endorse  your  issue  on  the  back  of  the  blank. 


190  HYGIENE 

3.  When  the  blank  is  returned  to  you  with  Part  II  executed,  you  will  determine 

whether  or  not  all  necessary  and  desirable  precautions  have  been  taken.  If 
you  find  these  satisfactory,  you  will  issue  an  order  on  the  state  board  of  health  for 
one  dollar  and  fifty  cents  (^l.SO),  in  favor  of  the  attending  physician.  If  not,  you 
will  order  the  additional  precautions  necessary. 

4.  You  will  transmit  to  the  attending  physician  (or  to  the  patient,  if  he  have  no 

physician),  a  Circular  of  Information  for  those  suffering  from  pulmonary  diseases, 
prepared  and  printed  by  the  state  board  of  health. 

INSTRUCTIONS  TO  ATTENDING  PHYSICIANS 

1.  On  receipt  of  this  circular  you  will  fill  Part  I,  which  is  a  statement  of  conditions 
as  you  find  them,  and  Part  III,  which  is  a  requisition  for  three  months'  supplies, 
and  mail  to  the  local  board  of  health. 

2.  The  circular  with  the  endorsement  of  your  requisition  will  be  returned  to  you  with 
one  quarter's  supplies  by  the  local  board  of  health. 

3.  You  will  then  state  upon  Part  III  what  precautions  you  have  taken  and  ordered, 

and  what  use  you  have  made  of  the  prophylactic  supplies. 

4.  If  these  are  satisfactory,  the  local  board  of  health  will  issue  an  order,  in  your 
favor,  upon  the  state  board  of  health  for  one  dollar  and  fifty  cents  (;J$1.50). 

Massachusetts 

The  state  board  of  health  has  its  office  in  the  State  House  at  Boston. 
An  examination  of  its  report  and  literature  impresses  me  that  it  is  doing  a 
solid  work  in  a  conservative  but  effective  way.  The  usual  regulations  for 
quarantine  and  vital  statistics  prevail,  and  state  inspectors  of  health  are 
appointed  who  work  under  the  supervision  of  the  state  board.  The  statutes 
provide  for  fifteen  of  these  inspectors  upon  an  adequate  salary,  and  the 
business  exigencies  of  the  state  are  such  that  these  men  are  practically  factory 
inspectors  as  well.  In  no  other  state  do  I  find  so  great  attention  given  to  the 
matter  of  factory  and  workshop  sanitation.  The  reports  upon  this  matter 
are  so  valuable  that  they  are  utilized  elsewhere  in  this  book  and  need  not  be 
further  discussed  here. 

The  cattle  bureau  operates  under  rigid  inspection  rules,  and  dairies 
throughout  the  state  are  inspected.  Even  dairies  in  adjoining  states  that  send 
their  products  into  Massachusetts  must  be  inspected  by  Massachusetts 
officials  regardless  of  state  lines.  The  1908  report  of  these  inspections  show 
that  the  New  England  states  have  much  to  do  in  improving  dairy  conditions. 

Food  and  drug  inspection  takes  the  time  of  several  officials  and  the 
reports  are  quite  interesting. 

The  Massachusetts  State  Sanatorium  at  Rutland,  the  first  state  insti- 
tution of  its  kind  in  this  country,  cares  for  tuberculous  cases,  as  do  also  the 
state  institutions  at  North  Reading,  Lakeville,  and  at  Westfield.  The  build- 
ings are  not  yet  all  completed. 

Michigan 

The  office  of  the  state  board  of  health  is  at  Lansing.  The  secretary  writes 
as  follows : 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  191 

Your  favor  of  the  13th  at  hand,  and  in  reply  thereto,  let  me  say  that  to  give 
you  a  full  idea  of  the  Michigan  plan  of  carrying  on  public  health  work,  I  am  sending 
you,  under  separate  cover,  a  copy  of  our  public  health  laws,  a  copy  of  our  quarterly 
publication,  "  Public  Health,"  last  issued,  a  copy  of  our  last  monthly  bulletin  "  Pub- 
lic Health,"  also  of  our  various  blanks  and  our  teachers'  edition  containing  instructions 
for  the  restriction  and  prevention  of  contagious  diseases. 

The  power  of  this  state  board  is  advisory  only,  having  in  connection  with  it  a 
bacteriological  and  chemical  laboratory  for  the  free  use  of  health  officials  throughout 
the  state. 

When  a  case  of  communicable  disease  occurs  in  a  community,  the  physician  is 
required  by  law  to  report  (also  the  householder  is  required  to  report)  the  case  to  the 
local  health  officer.  The  health  officer  is  required  by  law  to  investigate  and  take  the 
necessary  restrictive  measures,  and  report  to  the  state  board  of  health.  Upon  receipt 
of  report  we  send  out  contagious  disease  pamphlets  for  distribution  among  families 
and  neighbors,  or  where  they  will  do  the  most  good,  the  local  health  officer  attending 
to  the  distribution  of  same. 

Four  times  a  year  we  supply  the  teachers  and  others  with  our  quarterly  issue 
"  Public  Healch,"  which  we  attempt  to  make  readable  and  instructive  on  broader  lines 
of  public  health. 

The  monthly  bulletin,  "  Public  Health,"  is  a  current  summary  of  disease  condi- 
tions throughout  the  state,  issued  for  the  benefit  of  health  officials  and  physicians. 

These  publications  are  among  the  most  elaborate  issued  by  any  of  the 
boards,  and  to  them  we  are  indebted  for  considerable  data  used  in  the  body 
of  this  book.  The  state  university  at  Ann  Arbor  does  much  research  w^ork 
for  the  board  in  its  laboratory  of  hygiene.  It  was  in  that  university  laboratory 
that  the  editor  of  this  volume  received  his  start  in  the  study  of  the  problems 
of  hygiene  over  twenty  years  ago,  and  Michigan  at  that  time  was  in  advance 
of  most  of  the  more  eastern  states  in  research  work.  It  has  told  upon  the 
state  and  I  have  observed  since,  in  that  state,  that  the  general  public  well 
support  the  work. 

The  laws  under  which  the  board  bperate  are  drawn  with  special  care  and 
impress  me  as  fair  to  the  physician  and  as  elastic  enough  to  provide  for  con- 
tingencies ever  arising  in  health  administration.  They  do  what  all  states 
should  do,  designate  definitely  how  local  boards  of  health  should  organize  and 
conduct  their  work,  and  they  define  nuisances  in  a  manner  saving  the  officers 
a  world  of  trouble. 

The  university  maintains  a  Pasteur  laboratory  for  the  treatment  of  hydro- 
phobia and  the  board  sends  cases  there.  Michigan  is  conducting  an  aggres- 
sive campaign  against  tuberculosis  and  has  a  psychopathic  hospital  at  the 
university  for  the  reception  of  mild  cases  of  insanity.  This  latter  is  one  of  the 
later  but  most  humanitarian  phases  of  state  medicine  and  should  be  copied 
by  other  states. 

Minnesota 

The  Aiinnesota  State  Board  of  Health  has  offices  in  the  capitol  building 
at  St.  Paul.  New  regulation  is  pending,  but  it  is  principally  additional  to  an 
already  elaborate  code.  The  law  provides  for  the  appointment  of  a  board 
of"  nine  members,  learned  in  sanitary  science,"  but  the  work  is  largely  under 


192  HYGIENE 

the  supervision  of  the  secretary  and  executive  officer.  With  the  approval  of 
the  attorney  general  the  board  may  promulgate  rules  and  regulations  not  in 
conflict  with  any  statutes  or  the  charter  or  ordinances  of  a  city  of  the  first  class. 
These  regulations  have  the  effect  of  laws. 

The  board  has  adequate  regulations  regarding  sewage,  cemeteries,  hos- 
pitals, water  supply,  contagious  disease,  vaccination,  vital  statistics,  inter- 
state carriers,  nuisances,  and  food  inspection.  Legislation  passed  in  1907 
provided  good  county  organization  and  most  excellent  regulation  of  vital 
statistics  reports  and  their  collaboration. 

The  regulations  are  very  carefully  worked  out  in  detail,  following  the 
lines  of  other  states.  An  arrangement  to  secure  vaccination  without  the  fea- 
tures objected  to  in  many  places  commends  itself.     It  is  as  follows: 

VACCINATION 

16.  Following  an  exposure  of  smallpox  every  individual  who  cannot  show  evi- 
dence of  a  recent  successful  vaccination  or  a  recent  attack  of  smallpox  must  be  vacci- 
nated (within  three  (3)  days  of  che  first  exposure)  or  placed  under  the  same  isolation 
restrictions  as  smallpox  patients. 

If  smallpox  prevails  in  a  community  or  if  the  disease  appears  in  a  school,  all  un- 
vaccinated  teachers  and  pupils  must  be  excluded  from  school  for  a  period  of  three 
weeks  unless  vaccinated  within  three  (3)  days  of  first  exposure.  Failing  to  comply 
with  this  requirement,  the  school  must  be  closed  for  a  period  of  three  weeks. 

If  smallpox  appears  in  any  class  in  any  college  in  Minnesota,  all  unvaccinated 
teachers  and  students  in  the  class  must  be  excluded  from  recitations  for  a  period  of 
three  weeks  unless  vaccinated  within  three  (3)  days  of  first  exposure.  Failing  to  com- 
ply with  this  requirement,  the  classes  attended  by  such  teachers  or  students  must  be 
discontinued  for  a  period  of  three  weeks. 

Scarlet  fever  is  quarantined  for  three  weeks  or  longer,  depending  upon 
whether  or  not  desquamation  is  complete.  This  is  a  very  reasonable  provi- 
sion. Laboratory  findings  in  diphtheria  are  not  accepted  except  from  a 
laboratory  approved  by  the  board.  There  is  a  provisional  quarantine  for 
suspicious  cases  and  the  laboratory  findings  figure  largely  in  determining  the 
diagnosis.  The  board  has  a  laboratory  of  its  own.  When  a  house  is  plac- 
arded for  measles,  all  children  therein  must  remain  away  from  school  except 
those  who  have  previously  had  measles. 

The  following  very  wise  provision  is  made  as  regards  typhoid  fever: 

53.  Whenever  typhoid  fever  prevails  in  a  locality  the  local  board  of  health  shall 
immediately  appoint  a  competent  inspector,  or  inspectors,  to  patrol  the  city,  village,  or 
district  involved.  Such  inspector  or  inspectors  shall  report  to  the  local  board  of  health 
all  water  closets,  privies,  vaults,  and  cesspools  which  are  not  fly-proof,  with  screened 
doors  and  windows;  and  all  vaults  and  cesspools  which  are  not  water-tight,  dark,  and 
fly-proof  The  local  board  of  health  shall  thereupon  enter  its  proper  order  in  the 
premises  to  the  end  that  all  such  water  closets  and  privies  shall  be  made  fly-proof 
and  all  such  vaults  and  cesspools  water-tight,  dark,  and  fly-proof. 

54.  Any  drinking  water  supply  shown  to  be  a  positive  or  probable  source  of  dis- 
ease shall  be  condemned  either  by  the  local  board  of  health  or  by  the  Minnesota  State 
Board  of  Health,  and  when  so  condemned,  shall  nor  be  used  again  as  a  drinking  water 
supply  until  declared  safe  by  the  condemning  party. 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH 


193 


Minn. 


There  are  many  excellent  features  in  the  practical  conduct  of  the  work 
of  the  Minnesota  Board  largely  due  to  the  reasonableness  of  its  regulations. 
I  wish  to  refer  in  detail  to  the  advanced  position  this  board  takes  toward  the 
suppression  of  tuberculosis,  by  reproducing  a  few  of  its  blanks: 

REPORT  OF  A  CASE  OF  TUBERCULOSIS 

Name Age Sex Color 

Residence    County  of 

(Township,  Village,  or  City.) 

Occupation Married,  Single,  Widowed. 

(See  Special  Sheet  for  list  of  Occupa- 
tions.) 

In  returning  the  occupation  of  a  man, 
do  not  use  indefinite  terms. 

In  returning  the  occupation  of  a  woman 
remember  that  tuberculous  women  aban- 
don their  occupations  much  earlier  than 
do  tuberculous  men. 

The  occupation  to  be  named  is  of  the 
patient  at  the  time  the  disease  appeared. 
In  naming  occupation,  be  guided  by  the 
list  furnished. 
If  pulmonary  form: 

Coughing,  how  long  ? 
Expectorating  \     (Yes  or  no) 

Stage  of  disease  } How  long  tuberculous  ? 

Have  tubercle  bacilli  been  demonstrated  as  present  ?     (Yes  or  No.) 

If  so.  When  .?      By  Whom  .? 

Filled    out    by of 

Date  of  report 190 .... 

(Return  this  to  the  Minnesota  State  Board  of  Health  at  St.  Paul,  Minnesota) 


(Cross  out  all  except  proper  answer.) 

Nationality 

Birthplace     

Lungs,  Lymph 
Glands,  Perito- 
neum, Intestines, 
Genito    Urinary 
Tract,  Meninges, 
Skin,  Bones. 

(Cross  out  all  of  the  above  except  the 
proper  answer.) 


Location  of  Lesions 


Minn. 


By  Dr. 


REPORT  OF  A  CASE  OF  TUBERCULOSIS 
of  


19. 


Name  of  patient Age 

Residence    Birthplace 

(Township,  Village,  or  City.) 

Birthplace  of  Father Birthplace  of  Mother    

Male  or  Female Married,  Single,  or  Widowed 

Occupation White,  Colored,  Indian 

Is  the  patient  now  engaged  in  the  original  occupation  .? 

Is  the  earning  power  of  the  patient  as  good  as  ever  ^ 

If  working  irregularly  or  at  reduced  wages,  how  long  ? 

If  totally  unable  to  work,  how  long  .? 

If  totally  disabled,  is  the  patient  confined  to  bed  .^ 

If  there  has  been  consumption  in  the  family,  mark  in  the  list  below  those  who  were 

affected. 

Father  Mother  Brother  Daughter 

Father's  father  Mother's  father  Sister  Wife 

Father's  mother  Mother's  mother  Son  Husband 


194  HYGIENE 

Have  there  been  or  are  there  now  other  cases  in  the  house  ? 

If  patient  is  a  parent,  how  many  children  are  living  ? Dead  ? 

Are  there  infants  or  young  children  in  the  house  ? How  many  ? 

If  the  patient  is  a  mother,  is  she  nursing  an  infant  ? 

Does  the  patient  habitually  kiss  other  persons  on  the  mouth  ? 

Does  the  patient  use  dishes,  tableware,  handkerchiefs,  towels,  clothing,  pipes,  etc.,  in 

common  with  other  persons  ? 

Does  the  patient  prepare  the  food  for  the  family  ? 

DISPOSAL  OF  SPUTUM 

Does  the  patient  spit  upon  the  floor,  walls,  hearth,  or  furniture  ? 

Does  the  patient  spit  into  a  spittoon  used  by  other  persons  ? 

Does  the  patient  spit  into  a  handkerchief? 

Does  the  patient  spit  into  a  paper  napkin  ? 

Does  the  patient  spit  into  a  paper  sputum  cup  ? 

Does  the  patient  spit  into  a  china,  glass,  or  metal  sputum  cup  ?     If  so,  which  ? 

Is  water,  carbolic  acid,  or  any  disinfectant  used  in  the  sputum  cap  ? 

FINAL  DISPOSAL  OF  SPUTUM 

Is  the  sputum  burned  ? Is  it  thrown  into  a  water  close-  or  into  a  sewer  ? 

Is  it  thrown  upon  the  ground,  or  in"o  a  surface  drain  or  gutter  ? 

Is  it  thrown  away  with  garbage,  ashes,  or  other  refuse  ? 

Are  the  patient's  handkerchiefs  put  into  the  wash  with  other  clothing  ? 

Are  the  patient's  handkerchiefs  disinfected  before  being  laundered  ? 

CONDITION  OF  THE  ROOM 

Is  the  room  suitable  in  size,  ventilating,  and  lighting,  for  a  tuberculous  person  ? 

Arethehangings,  floor  coverings,  or  furniture  such  as  to  admit  of  proper  disinfection  ?.  . 
How  are  the  walls  finished   (rough  plaster,  smooth  plaster,  wainscoted,  papered 

painted)  ? 

Are  the  walls  and  furniture  ever  wiped  off"  with  a  disinfecting  solution  ? , 

Is  the  room  swept  and  dusted  in  the  ordinary  way  with  broom  and  duster  ? 

Is  the  floor  ever  washed  with  a  disinfecting  solution  ? 

How  many  persons  occupy  the  patient's  bedroom  ? 

Does  any  one  share  the  patient's  bed  ? 

Is  the  patient's  bedroom  used  as  a  kitchen  ? Asa  dining  room  ? 

Do  children  play  on  the  floor  of  patient's  bedroom  ? 

Do  you  find  any  other  conditions  in  the  patient's  room  which  in  your  opinion  may  be 

a  source  of  danger  to  those  on  the  premises,  or  to  the  public  ? 

(To  be  sent  to  a  Physician  one  month  after  a  prophylactic  outfit  has  been  fur- 
nished him  for  a  tuberculous  patient.) 

RELATING  TO  PRECAUTIONS  TAKEN  IN  THE  CARE  OF  THE 
TUBERCULOUS 

Return  this  to  the  Secretary  of  the  Minnesota  State  Board  of  Health,  St.  Paul,  Minn. 

19 

Name  of  patient Age 

Residence    

(Township,  Village,  or  City.) 
Was  the  room  of  the  pacient  in  such  condition  as  to  require  formaldehyde  disinfection 

before  other  prophylactic  steps  were  taken  f 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  195 

If  the  patient  is  a  nursing  mother  with  an  infant,  have  you  advised  her  of  the  danger 
of  nursing  it  ? 

Have  you  advised  the  patient  not  to  kiss  any  one  on  the  mouth  ? 

Have  you  instructed  the  patient  to  hold  a  handkerchief  or  napkin  before  the  face  when 
coughing  ?   

Have  you  given  directions  for  the  patient  to  have  for  exclusive  personal  use  all  utensils 
and  articles  which  come  in  contact  with  the  mouth  ? 

Have  you  forbidden  the  use  by  others  of  the  patient's  utensils  or  wearing  apparel  ?.  . .  . 

Have  you  ordered  the  disinfection  of  washable  clothing  before  the  same  is  laundered  ?.  . 

If  the  patient  prepares  or  handles  food  for  the  family,  have  you  given  careful  instruc- 
tions how  to  avoid  contaminating  the  food  ? 

Have  you  instructed  the  panent  to  wash  and  disinfect  the  hands  frequently,  especially 
when  performing  any  household  duties,  and  how  to  avoid  contaminating  the 
hands  ? 

Have  you  instructed  the  patient,  and  at  least  oneother  responsiblememberof  thehouse- 
hold,  concerning  the  disinfection  of  the  hands  and  utensils,  and  the  accidental 
contamination  of  surroundings  ? 

Have  you  ordered  that  every  accidental  contamination  with  sputum  be  disinfected 
immediately  ? 

Have  you  forbidden  the  patient  to  expectorate  anywhere  except  into  proper  receptacles  ? 

Have  you  ordered  that  the  soiled  sputum  cups  be  burned   after  use  not  exceeding 

forty-eight  hours  ? 

Have  you  directed  the  use  of  paper  napkins  and  waterproof  pockets  for  the  soiled 

napkins  when  the  patient  is  away  from  home  ? 

Have  you  ordered  that  the  soiled  paper  napkins  be  burned  daily  ? 

Have  you  forbidden  the  throwing  of  sputum  upon  the  ground  or  into  surface  drains  or 

gutters  ? 

Have  you  forbidden  the  throwing  away  of  sputum  with  garbage,  ashes,  or  refuse  ?.  . .  . 
Do  the  patient's  circumstances  adm.it  of  special  furnishings  and  the  proper  arrange- 
ments of  the  sickroom  ? 

If  so,  have  you  made  the  following  recommendations  ? 

The  removal  of  heavy  curtains  ? 

The  use  of  sash  curtains  or  other  curtains  of  washable  material  ? 

The  removal  of  carpets  ? 

The  use  of  rugs,  preferably  of  cotton  or  other  washable  material  ? 

The  removal  of  large  and  unnecessary  pieces  of  furniture,  especially  such  as  inter- 
fere with  the  thorough  cleansing  of  the  room  ? 

Have  you  ordered  the  walls,  floors,  and  furniture  wiped  off  once  a  week  with  a  cloth  wet 

with  a  disinfecting  solution  ? 

Have  you  forbidden  dry  sweeping  and  dusting  in  the  patient's  room  ? 

Have  you  advised  against  the  patient's  sleeping  with  any  other  person  ? 

Is  it  possible  to  have  the  patient  sleep  alone  in  a  room  ? 

Have  you  advised  against  preparing  food  for  or  serving  food  to  other  persons  in  the 

patient's  room  ? 

Have  you  advised  that  children  should  not  be  allowed  to  play  on  the  floor  of  the 

patient's  room  ? 

Mississippi 

The  Mississippi  State  Board  of  Health  has  offices  at  Jackson.      This 
state  is  a  party  to  the  "  Quarantine  Rules  and  Regulations  of  the  South 


196  HYGIENE 

Atlantic  and  Gulf  Coast  States,"  and  which  are  directed  against  yellow  fever 
and  all  kinds  of  infected  shipping  and  freight  as  well  as  passengers  arriving 
from  infected  ports  or  districts.  Elaborate  regulations  as  to  inspection  and 
disinfection  are  outlined  and  the  whole  work  is  supervised  by  an  inspector 
employed  by  the  United  States  Marine  Hospital  Service. 

Aside  from  this,  the  state  has  regulations  of  its  own  similar  to  those  of 
other  states,  but  which  are  brief  and  to  the  point.  It  lays  especial  emphasis 
upon  cholera  and  yellow  fever  and  some  of  the  requirements  as  to  burial, 
funerals,  the  relays  of  guards,  the  passage  of  trains,  etc.,  are  so  gruesome 
as  to  emphasize  the  terrors  of  this  scourge.  The  mosquito  dissemination 
theory  will  modify  some  of  the  features  of  such  quarantine. 

The  board  employs  a  state  lecturer  to  visit  all  of  the  towns  of  the  state 
and  they  are  preparing  a  full  set  of  bulletins  for  circulation  among  the  people. 
The  state  is  doing  a  good  work  and  is  organizing  the  counties. 

Missouri 

The  state  board  of  health  does  not  have  a  central  office  at  the  state  capitol, 
but  the  secretary  of  the  board,  Dr.  J.  A.  B.  Adcock,  Warrensburg,  receives 
the  reports  and  issues  the  very  excellent  bulletin  as  a  quarterly  entered  as 
second-class  mail  matter.  The  board  numbers  seven  members,  five  of 
whom  must  be  physicians.     All  of  the  present  board  are  medical  gentlemen. 

The  board  operates  under  a  brief  but  workable  code  of  laws  and  is  author- 
ized to  take  such  measures  as  circumstances  may  demand,  is  required  to  take 
cognizance  of  diseases  among  domestic  animals,  and  acts  as  a  state  board  of 
medical  examiners. 

County  boards  are  composed  of  the  iudges  of  the  county  courts  and  one 
physician,  selected  by  them,  for  each  county.  These  boards  are  subsidiary 
to  the  state  board  and  they  operate  under  brief  but  effective  rules  governing 
quarantine,  sanitation,  and  school  regulations.  There  is  a  state  bacterio- 
logist and  a  Missouri  State  Sanitarium  for  tubercular  cases. 

Montana 

The  department  of  public  health  is  located  at  Helena,  the  membership 
being  composed  of  the  governor,  the  attorney  general,  four  physicians,  n  d  a 
veterinarian.  The  laws  under  which  the  board  operates  have  been  recently 
amended. 

Nebraska 

The  state  board  of  health  is  composed  of  the  governor,  the  attorney  gen- 
eral, the  superintendent  of  public  instruction,  a  board  of  secretaries,  and  a 
state  health  inspector.     The  office  is  at  Lincoln. 

The  law  under  which  the  board  conducts  its  work  is  so  framed  as  to  give 
great  recognition  to  local  boards  when  they  properly  perform  their  functions, 
but  also  to  give  the  state  authority  to  safeguard  the  health  of  delinquent  com- 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  197 

munities.  The  quarantine  regulations  are  up  to  the  standard  of  the  most 
advanced  practice,  and  inspection  of  schools,  vital  statistics,  and  other  de- 
partments of  state  hygiene  are  provided  for  in  a  carefully  drawn  code  of  laws 
and  regulations. 

Nevada 

The  Nevada  State  Board  of  Medical  Examiners,  through  its  secretary, 
who  is  also  secretary  of  the  board  of  health,  has  endeavored  to  secure  a  proper 
recognition  for  their  work  but  with  little  success.  The  secretary  writes:  "  I 
am  sorry  to  say  this  state  is  doing  nothing  along  the  lines  you  mention.  I 
endeavored  to  get  some  legislation  and  appropriation  for  above  purposes  at 
the  session  of  the  legislature  that  ends  to-morrow,  but  was  not  successful. 
In  sackcloth  and  ashes." 

Nevada  is  a  young  state  and  the  secretary  is  an  earnest  man  and  it  will 
probably  not  be  long  until  this  state  will  swing  into  line. 

New  Hampshire 

The  state  board  of  health  has  its  offices  in  the  State  House  at  Concord 
and  is  allied  with  the  board  of  commissioners  of  lunacy,  the  department  of 
vital  statistics,  and  the  state  laboratory  of  hygiene.  This  state  has  snug  and 
workable  sanitary  laws  and  rigid  ones  concerning  food  and  drugs.  The  local 
boards  are  well  organized,  nuisances  are  well  defined,  quarantine  regulations 
are  adequate,  swamp  lands  come  under  state  care,  building  and  improvement 
measures  are  provided,  and  the  physicians  are  paid  small  fees  for  vital  statistics 
reports. 

The  state  maintains  a  tuberculosis  sanatorium  and  the  board  publishes 
a  very  good  sanitary  bulletin,  as  well  as  other  literature  for  the  information  of 
health  officers  and  the  public.  The  laboratory  of  hygiene  conducts  a  high 
grade  of  research  work  and  the  board  is  making  a  most  careful  investigation 
of  the  water  supplies  of  the  state. 

Food,  drug,  and  liquor  inspection  is  developed  to  an  extent  in  New  Hamp- 
shire equalled  by  very  few  other  states.  They  are  doing  a  fearless  and 
effective  work  commented  upon  in  other  portions  of  this  book,  and  that 
need  not  be  fully  discussed  here.  Suffice  it  to  say  that  the  federal  government 
accepts  as  authoritative  the  work  of  this  laboratory  and  it  is  permitted  especial 
privileges  in  the  federal  courts. 

New  Jersey 

In  Chapter  XI  detailed  reference  is  made  to  the  excellent  provisions  of 
this  state  board  of  health  as  regards  the  training  of  local  health  officers,  a 
plan  every  state  should  copy.  The  public  health  laws  are  so  detailed  as  to 
render  an  abstract  of  them  too  lengthy  for  these  pages.  In  general  it  can  be 
said  that  they  have  been  brought  more  fully  up  to  date  than  are  the  codes  of 
most  of  the  eastern  states. 


198  HYGIENE 

Section  VI  provides:  "  That  every  physician  in  this  state  making  official  reports 
to  the  state  board  of  health  through  the  bureau  of  vital  statistics  shall  be  entitled  to 
receive  by  mail,  from  the  treasurer  of  the  state,  a  copy  of  the  annual  report  of  the  state 
board  of  health  and  of  the  bureau  of  vital  statistics." 

In  addition  to  this,  every  physician  making  reports  receives  a  semi- 
annual remittance  for  his  trouble.  The  splendid  sanitary  inspection  service 
provides  the  foUov^ing  books  for  study : 

"  Principles  of  Sanitary  Science,"  by  W.  T.  Sedgwick,  published  by  McMillan  & 
Co.,  price,  ;^3.  "  Practical  Hygiene,"  by  Charles  Harrington,  published  by  Lea  Bros. 
&  Co.,  price,  $4.25.  "Manual  of  Hygiene  and  Sanitation,"  by  Seneca  Egbert,  pub- 
lished'by  Lea  Bros.  &  Co.,  price,  $2.25.  "  Clean  Milk,"  by  S.  D.  Belcher,  pub- 
lished by  the  Hardy  Publishing  Company,  price,  $1.  Circulars  of  the  board  of  health 
of  the  state  of  New  Jersey  will  be  sent  upon  request. 

Partial  provision  is  made  for  placing  inspectors  who  have  passed  the 
examination  under  civil  service  rules.  The  series  of  circulars  issued  are  of  a 
reasonable  and  scientific  tone  and  calculated  to  impress  a  layman.  An  ex- 
cellent tuberculosis  campaign  is  in  progress.  By  revision  the  food  and  drug 
laws  of  the  state  have  been  brought  into  conformity  with  federal  regulations. 

The  officers  of  the  board  are  at  Trenton,  as  is  also  the  well-equipped  state 
laboratory  of  hygiene.  A  good  provision  of  the  laboratory  is  the  host  of 
repositories  for  mailing  cases  scattered  all  over  the  state  and  thus  facilitating 
reports. 

New  Mexico 

The  New  Mexico  Board  of  Health  and  Medical  Examiners  is  composed 
of  seven  physicians,  the  office  of  the  secretary  being  at  Santa  Fe.  This  grow- 
ing state  has  been  attending  to  sanitary  matters  arising,  but  the  laws  under 
which  the  board  operates  are  inadequate  and  are  undergoing  revision  looking 
toward  an  effective  and  up  to  date  service. 

New  York 

As  is  to  be  expected,  New  York  maintains  an  elaborate  department  of 
health  with  a  commissioner  and  divisions  of  sanitary  engineering,  laboratory 
work,  vital  statistics,  communicable  diseases,  publicity  and  education,  a  con- 
sulting staff  and  a  tuberculosis  advisory  board.     The  offices  are  at  Albany. 

The  department  conducts  the  work  common  to  all  states,  but  is  espe- 
cially marked  by  its  energetic  tuberculosis  work,  the  school  of  sanitar}'  science 
and  public  health  maintained  at  Cornell  University,  and  the  many  lines  of 
research  work  conducted  and  which  would  take  much  space  to  detail.  The 
protection  of  the  public  water  supply  is  a  serious  problem  in  a  densely  popu- 
lated region  and  this  department  is  giving  much  attention  to  the  matter  largely 
aided  by  the  division  of  sanitary  engineering,  a  vital  part  of  a  state  department 
and  one  in  which  so  many  states  are  weak.  As  yet  pure  food  work  is  not  ver}' 
largely  undertaken,  but  plans  are  being  made  for  an  aggressive  campaign 

Vital  statistics  and  quarantine  are  looked  after  in  a  very  well-organized 
way.  The  department  maintains  an  antitoxin  laboratory  and  distributes  a 
large  amount  every  year.     There  is  also  a  cancer  laboratory. 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  199 

Systematic  effort  is  made  to  train  the  many  local  health  officers,  and  a 
circulating  library  is  maintained  for  their  use.  The  local  boards  over  the 
state  seem  to  be  doing  good  work. 

The  department  issues  a  monthly  bulletin  and  many  circulars  promoting 
popular  sanitary  education. 

(See  the  final  section  of  Chapter  XI  for  a  discussion  of  the  work  in  New 
York  city.) 

North  Carolina 

The  business  of  the  board  is  conducted  from  the  office  of  the  secretary 
in  Raleigh.  The  quarantine  regulations  are  brief,  but  seem  to  me  to  be  well 
drawn,  and  the  regulations  concerning  local  boards  are  adequate. 

The  state  laboratory  of  hygiene  is  evidently  doing  a  good  work,  and  pro- 
vides facilities  for  the  physicians  of  the  state  in  the  many  directions  under- 
taken by  such  laboratories. 

North  Dakota 

The  work  of  the  state  board  of  health  is  conducted  from  the  office  of  the 
secretary,  Dr.  J.  Grassick,  Grand  Forks.  The  revised  statutes  of  the  state 
apply  to  superintendents  of  county  boards,  health  officers  of  cities,  and  town- 
ship supervisors.  These  men  are  responsible  for  the  enforcement  of  a  well- 
devised  code  of  laws  that  includes  school  vaccination,  the  non-employment  of 
tuberculous  teachers,  adequate  quarantine,  provisional  quarantine  in  sus- 
picious cases,  the  regulation  of  milk  supply,  vital  statistics  reports,  and  reports 
twice  weekly  by  attending  physicians  of  the  progress  of  infectious  cases  in 
their  practice. 

The  bureau  of  vital  statistics  is  under  a  state  registrar  and  many  local 
deputies,  and  quite  a  complete  code  of  laws  and  full  reports  guarantee  a  useful 
state  work  in  this  important  division.  There  are  twelve  hundred  local  regis- 
trars and  about  seventy  health  officers  in  the  state. 

The  board  publishes  an  excellent  monthly  bulletin.  As  illustrative  of 
feeling  in  what  the  East  regards  as  the  West,  an  extract  is  given  from  its 
pages: 

North  Dakota  has  now  reached  that  stage  in  its  development  when  it  must  take 
its  place  alongside  of  the  older  states  in  everything  that  pertains  to  its  material  pro- 
gress. It  is  no  longer  on  the  western  border  of  civilization,  but  right  in  the  center  of  the 
most  enlightened  section  of  our  country.  Its  soil  has  been  so  productive  that  it  has 
earned  the  title  of  "  the  breadbasket  of  the  world."  Its  institutions  of  learning  are 
turning  out  scholars  that  are  winning  laure's  when  pitted  against  the  graduates  of 
eastern  schools.  Our  citizenship  is  of  as  high  a  grade,  morally,  intellectually,  and 
physically  as  that  of  any  sia.  e  in  the  Union;  and  it  only  remains  for  us  to  fill  in  some 
of  the  gaps  to  make  us  a  model  of  statehood.  One  of  the  most  important  institutions 
of  any  state  is  that  of  the  department  of  public  health.  In  the  conservation  of  the 
health  of  our  people  lies  the  chief  factor  for  our  economic  and  material  progress.  We 
have  in  a  measure  escaped  some  of  the  sanitary  problems  that  confront  older  states,  but 
we  have  now  approached  that  stage  in  our  development  where  they  can  no  longer  be 
overlooked. 


200  HYGIENE 


O 


HIO 


The  state  board  of  health  conducts  its  business  through  the  office  of  the 
secretary  at  Columbus.  An  engineering  division  is  maintained  and  good 
laboratory  service  is  provided.  The  dairy  and  food  commissioner  has  charge 
of  the  food  problem  and  the  laws  he  is  charged  to  enforce  are  drawn  along 
modern  lines.  The  laws  regarding  nuisances  might  be  copied  to  the  advan- 
tage of  some  other  states. 

Particularly  commendable  is  the  law  prohibiting  the  reception  of  the 
tuberculous  in  county  infirmaries  or  "  poorhouses  "  and  requiring  either  sepa- 
rate buildings  to  be  erected  upon  the  infirmary  grounds  or  the  erection  of  a 
separate  institution  by  the  commissioners  of  every  county  not  otherwise  pro- 
vided with  a  suitable  tuberculosis  hospital  for  the  reception  of  charity  cases. 

Proper  provision  is  made  for  the  organization  of  local  boards  of  health 
and  for  the  regulation  of  corporate  sanitation. 

The  board  has  widely  circulated  a  very  good  series  of  circulars  upon  the 
various  contagious  diseases  and  has  issued  a  very  practical  pamphlet  upon 
"  Disinfection  and  Disinfectants." 

Oklahoma 

The  state  commissioner  of  health  has  his  office  at  Shawnee,  from  which  is 
handled  an  adequate  work  along  several  lines,  inclusive  of  food,  dairy,  and 
drug  inspection,  the  regulation  of  hotels,  etc. 

Indian  Territory  became  a  part  of  Oklahoma  when  that  state  was 
created,  but  the  Indians  are  still  largely  under  the  control  of  the  Department 
of  the  Interior.  The  report  of  the  commissioner  to  the  five  civilized  tribes  to 
the  Secretary  of  the  Interior  (1908)  reveals  that  the  m.aterial  interests  and  edu- 
cation of  the  Indians  is  being  much  more  fully  looked  after  than  is  thought 
to  be  the  case  by  some  advocates  of  reform  in  the  Indian  service.  The  re- 
ports of  the  governor  of  Oklahoma  show  an  efficiency  in  health  work  in  the 
state,  but  that  insane  and  other  institutional  buildings  are  needed.  The  last 
official  map  of  Oklahoma  shows  the  immense  strides  taken  by  this  state 
during  the  last  few  years. 

Oregon 

The  state  board  of  health  consists  of  seven  physicians,  one  of  whom  is 
the  state  health  officer.  A  bacteriologist  is  employed  and  the  office  is  in 
Room  422,  Marquam  Building,  Portland. 

The  legislation  is  brief,  but  confers  fairly  full  powers  upon  the  board, 
which  has  issued  rules  covering  quarantine,  school  vaccination,  vital  statistics, 
dairy  inspection,  and  many  other  lines  of  state  sanitation.  The  counties  are 
organized  and  are  under  the  state  regulations. 

The  board  issues  a  bi-monthly  bulletin  of  general  interest. 

Pennsylvania 

The  state  department  of  health  is  housed  in  the  state  capitol  building  at 
Harrisburg,  and  has  the  most  elaborate  set  of  offices  of  any  health  board  in  the 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  201 

United  States  and  probably  the  largest  force  of  employees.  The  law  under 
which  it  operates  is  the  most  far-reaching  one  ever  enacted,  and  the  legisla- 
ture has  conferred  very  unusual  powers  upon  the  commissioner,  who  is 
probably  the  most  powerful  officer  in  the  state. 

Section  VHI  reads:  It  shall  be  the  duty  of  the  commissioner  of  health  to  protect 
the  health  of  the  people  of  the  state,  and  to  determine  and  employ  the  most  efficient  and 
practical  means  for  the  prevention  and  suppression  of  disease. 

An  order  of  the  department  has  the  effect  of  law,  the  agents  of  the  de- 
partment have  right  of  entry,  and  certain  ones  of  arrest,  and  Section  16  of  the 
law  provides: 

Any  person  who  violates  any  order  or  regulation  of  the  department  of  health,  or 

who  resists  or  interferes  with  anyofficeror  agent  thereof  in  the  performance  of  his  duties 

....  shall  be  deemed  guilty  of  a  misdemeanor,  and  shall  upon  conviction  thereof  be 

punished  by  a  fine  of  not  more  than  ;^100,  or  by  imprisonment  not  exceeding  one 

month,  or  both." 

The  department  has  absolute  power  over  nuisances  and  can  order  munici- 
palities, local  boards,  corporations,  physicians,  and  others  to  put  its  regula- 
tions into  effect  as: 

The  commissioner  of  health  is  furthermore  empowered  to  revoke  or  modify  any 
order,  regulation,  by-law,  or  ordinance  passed  by  any  local  board  of  health  if  he  thinks 
it  will  work  injury  to  the  public  health  outside  the  territory  over  which  the  local  board 
has  control.  He  may  also  issue  warrants  to  any  sheriff,  constable, or  policeman  for  the 
arrest  of  those  who  disobey  quarantine  orders  or  the  department's  regulations,  and  he 
may  subpoena  witnesses.     The  commissioner's  salary  is  ;^10,000  a  year. 

The  work  is  carried  on  under  divisions  of  medical  inspection,  sanitary 
engineering,  vital  statistics,  morbidity  statistics,  antitoxin  distribution,  and 
subsidiary  organization.  There  is  a  very  large  office  and  clerical  force, 
1,153  local  registrars,  730  health  officers,  67  county  medical  inspectors,  a 
varying  but  large  force  in  the  engineering  work,  108  tuberculosis  dispen- 
saries with  staffs  of  physicians  and  nurses,  a  laboratory  maintained  at  the 
Universityof  Pennsylvania,  and  a  total  force  aggregating  over  three  thousand 
persons  upon  salaries  or  per-diem  fees. 

The  last  legislature  appropriated  ^3,000,000  for  the  next  two  years'  work, 
inclusive  of  antituberculosis  hospitals,  but  not  covering  any  work  along  pure- 
food  lines,  which  is  under  the  dairy  and  food  commissioner,  nor  veterinary 
sanitation,  which  comes  under  the  agricultural  department.  The  law  also 
imposes  large  expense  upon  city  and  other  local  boards. 

The  engineering  division  of  the  department  is  the  best  in  the  United 
States.  The  division  of  vital  statistics  is  highly  elaborated  and  requires  a 
great  deal  of  physicians  in  practice  in  the  state,  but  does  not  remunerate  them 
for  services  involved.  The  reports  expected  cover  a  wide  field,  inclusive  of 
malaria  and  all  other  infections,  and  the  rules  governing  physicians  are  of  a 
rigid  character. 

Local  boards  are  subsidiary  to  the  state  organization.  The  free  distri- 
bution of  antitoxin  is  upon  a  liberal  scale  and  antituberculosis  work  is  elab- 
orately organized. 


202  HYGIENE 

There  is  an  immense  work  to  do  in  Pennsylvania,  owing  to  the  large 
foreign  element  in  the  population,  and  whole  sections  populated  with  a  semi- 
Americanized  class  of  persons  densely  ignorant  so  far  as  sanitation  is  con- 
cerned. In  the  past  many  local  boards  were  mere  political  ornaments,  and  it 
is  a  big  proposition  to  awaken  the  state  to  a  sense  of  its  dangers  and  its  needs. 
In  the  larger  cities  a  good  work  has  been  done  for  years  past,  and  the  new 
department  of  health  has  done  little  to  modify  their  work  except  to  require 
them  to  report  to  Harrisburg. 

Some  very  skilled  men  are  employed  by  the  department  and  a  very 
aggressive  work  is  being  done  under  an  organization  differing  radically  from 
those  of  most  other  states.  Time  only  will  tell  just  what  legal  provisions  will 
best  suit  state  work,  but  Pennsylvania  is  tr}-ing  an  ambitious  experiment, 
thus  far  with  success.  But  it  is  very  expensive  and  many  states  could  not 
afford  so  large  an  outlay. 

Philippine  Islands 

The  bureau  of  health  for  the  Philippine  Islands  is  a  model  of  organiza- 
tion, working  under  regulations  more  advanced  than  are  those  of  most  of 
the  states  in  the  Federal  Union.  Sanitation  is  made  one  of  the  first  cares  of 
the  ?dministration,  and  the  printed  regulations  kindly  sent  to  me  are  too 
extensive  to  be  detailed  here.  They  are  referred  to  in  some  of  the  chapters 
of  this  book. 

Medical,  dental,  and  pharmaceutical  practice  are  all  regulated  very 
rigidly;  pharmacists  being  more  restricted  than  in  the  states,  although 
Chinese  pharmacists  may  sell  their  wares  to  the  Chinese.  Especially  to  be 
commended  is  the  admirable  anti-opium  law  and  the  humane  and  sanitary 
administration  of  prisons.  We  have  due  occasion  to  be  proud  of  the  record 
being  made  by  our  federal  sanitation  of  the  tropics. 

The  appended  letter  is  self  explanatory: 

The  government  of  the  Philippine  Islands  has  established  a  bureau  of  health  under 
the  charge  of  a  director  of  health,  and  all  local  health  officers  of  the  Philippine  Island 
not  only  report  to  the  bureau  of  health,  but  are  directly  subject  to  the  orders  of  the 
director  of  health. 

Both  the  director  of  health  and  the  assistant  director  of  health  are  passed  assistant 
surgeons  of  the  United  States  Public  Health  and  Marine  Hospital  Service. 

The  bureau  of  health  is  one  of  the  largest  and  most  important  bureaus  of  the 
government  of  the  Philippine  Islands  and  handles  an  annual  appropriation  of  about 
^700,000,  United  States  currency.  This  does  not  include  the  local  appropriations  for 
health  work,  which  amount  to  about  ^100,000,  United  States  currency  for  all  purposes. 
There  is  maintained  a  bureau  of  science,  which  also  deals  largely  with  health 
matters,  especially  in  the  preparation  of  serums  and  vaccines,  and  in  research  work 
on  its  own  account  and  for  the  bureau  of  health. 

I  shall  be  pleased  to  assist  you  further  in  any  way  in  which  I  can  be  of  service. 

Very  respectfully, 

Victor  G.  Heiser, 
Passed  Assistant  Surgeon,  U.  S.  P.  H.  and  M.  H.  S.,  Director  of  Health. 
Executive  Bureau,  Manila,  P.  I.,  April  26,  1909, 
to  the  Bureau  of  Insular  Affairs. 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  203 

Puerto  Rico 

Sanitation  is  under  the  charge  of  the  United  States  Public  Health  and 
Marine  Hospital  Service,  described  in  Chapter  XH  (q.v.).  The  work  is  in 
charge  of  Dr.  M.  H.  Foster  of  the  service,  and  is  discussed  in  detail  in  various 
reports  of  the  service.  The  principal  problems  to  be  met  are  maritime  quar- 
antine and  hookv^orm  disease. 

Rhode  Island 

This  state  maintains  a  good  system  of  registration  of  vital  statistics  and, 
I  am  told,  is  manned  by  good  men  doing  a  good  work.  The  secretary  has 
favored  me  with  the  following  account  of  the  work: 

In  reply  to  your  inquiry  concerning  the  work  of  the  state  board  of  health  I  will 
state  that  we  have  no  circulars  which  explain  all  the  work,  but  our  line  of  investigai  ion 
inc'udes  the  investigation  of  water  and  sewage  supplies  throughout  the  state;  spring 
waters  and  ice  supplies;  the  examination  of  diphtheria  cultures;  the  free  distribution 
of  diphtheria  antitoxin;  examination  of  sputum  and  free  distribution  of  spit  cups  for 
tuberculosis  (the  latter  to  the  extent  of  fifty  thousand  last  year);  the  education  of 
people  on  the  subject  of  tuberculosis  by  means  of  a  tuberculosis  exhibit,  lectures,  litera- 
ture, etc.;  and  the  examination  for  Widal  reaction. 

The  advice  in  reference  to  water  supplies  and  filtration  works  and  general  advice 
in  reference  to  control  of  contagious  diseases. 

Quarantine  is  maintained  only  slightly  on  the  maritime  division  by  the  cities  of 
Newport  and  Providence.  Our  foreign  connections  are  very  slight,  being  mostly  the 
Cape  Verde  Islands. 

Yours  truly, 

Gardner  T.  Swarts, 

Secretary. 

South  Carolina 

The  secretary  and  state  health  officer  of  the  state  board  of  health  writes 
me  that  the  laws  governing  the  board  are  being  codified,  and  that  several  im- 
portant acts  have  been  recently  passed,  bringing  their  work  up  to  date. 
The  last  compilation,  1901,  I  have  examined,  and  the  laws  are  a  good  founda- 
tion for  an  excellent  code.  The  board  is  publishing  an  excellent  series  of 
pamphlets  upon  communicable  disease,  for  general  distribution. 

South  Dakota 

The  office  of  the  superintendent  and  ex-officio  secretary  is  at  Tyndall, 
from  which  place  the  business  of  the  state  board  of  health  is  conducted.  It 
would  be  unfair  to  enter  into  much  detail  with  regard  to  the  work  of  this 
board,  since  they  are  at  work  revising  their  rules.  The  rules  and  regulations 
published  in  May,  1908,  are  brief,  but  indicate  that  the  board  is  well  organized 
for  necessary  work.  A  noticeable  feature  of  their  rules  is  that  a  definite 
quarantine  period  is  not  set  as  to  days  or  weeks.     Sometimes  I  feel  that  such  a 


204  HYGIENE 

latitude  as  South  Dakota  allows  is  wise.  For  instance,  I  have  under  my  care 
at  present  a  very  mild  case  of  "  scarlet  rash  "  and  desquamation  was  over 
remarkably  soon  and  the  child  hardly  ill  at  all.  Yet  the  business  place  where 
the  patient  is  must  be  quarantined  for  forty  days,  despite  the  fact  that  all 
danger  is  over  before  so  long  a  period.  On  the  other  hand,  I  have  had 
patients  who  should  be  quarantined  for  fifty  days  or  more.  The  rules  re- 
ferred to  are  here  appended : 

Diphtheria — For  the  patient:  Isolation  for  fourteen  (14)  days  after  recovery  and 
disinfection  of  premises.  For  persons  associated  with  or  in  the  house  with  the  patient: 
Quarantine  until  after  death  or  recovery  of  the  patient  and  disinfection  of  the  premises. 

Scarlet  Fever  —  Isolation  of  the  patient  and  quarantine  of  children  associated  with 
or  in  the  house  with  the  patient  for  ten  (10)  days  after  complete  desquamation  or  scaling 
of  patient  and  disinfection  of  the  premises. 

Smallpox  —  For  the  patient:  Isolation  until  after  all  crusts  or  scales  have  fallen 
off  and  the  disinfection  of  the  premises.     For  exposed  persons:  Vaccination  at  once. 

Cholera  and  Yellow  Fever — For  the  patient:  Isolation  until  after  complete 
recovery  and  disinfection  of  premises.  For  exposed  persons:  Quarantine  for  five  (5) 
days  from  date  of  last  exposure. 

Typhus  Fever  —  For  the  patient:  Isolation  until  after  complete  recovery  and  dis- 
infection of  the  premises.  For  exposed  persons:  Quarantine  for  twenty-one  (21)  days 
from  the  date  of  last  exposure. 

Tennessee 

The  motto  of  this  state  board  of  health  is,  "  Public  Health  is  Public 
Wealth,"  and  yet  there  are  few  states  with  such  wideawake  health  officials 
that  appropriate  so  little  of  the  public  wealth  for  the  public  health.  The 
biennial  report  of  this  board  is  one  of  the  best  published  in  the  country  and  is 
an  instructive  volume  of  about  five  hundred  pages,  and  yet  the  state  appro- 
priation for  two  years'  work  was  only  ^21,800,  and  but  ^12,510  was  actually 
used,  and  that  covered  pure  food  work  in  addition.  Pennsylvania  appro- 
priates two  hundred  and  forty  times  as  much,  and  pays  its  commissioner  a 
larger  salary  than  the  whole  Tennessee  appropriation.  All  I  can  say  is,  that 
I  cannot  see  how  Tennessee  does  it.     "  Sweet  are  the  uses  of  adversity." 

As  nearly  as  I  can  figure  out  the  problem,  Tennessee  has  a  pretty  sensible 
code  of  laws  and  makes  the  county  and  municipal  boards  of  health  attend  to 
things  and  gives  them  the  necessary  power  to  enforce  their  orders  even  for  a 
mile  beyond  the  municipal  limits.  The  state  health  officers  seem  to  be  self- 
sacrificing  men,  the  pure  food  and  drug  inspector,  for  instance,  using  his  own 
building  and  purchasing  his  own  equipment  for  the  work,  and  personally  col- 
lecting and  analyzing  five  hundred  and  seventeen  samples  collected  from  all 
over  the  state,  and  all  on  |!  1,9 50  expenditure  for  two  years.  The  women's 
clubs,  the  schools,  the  railroads,  and  numerous  organizations  are  carrying 
on  an  aggressive  antituberculosis  work.  The  watersheds  of  the  state  are 
being  plotted,  the  public  institutions  are  under  sanitary  inspection  the 
water  supply  is  being  carefully  supervised,  every  county  is  organized,  the 
medical  societies  are  active  in  sanitary  work,  schools  are  being  looked  after 
and  the  regulations  of  the  state  board  are  fully  up  to  date.     The  state  is  a 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  205 

splendid  instance  of  how  much  can  be  donewith  little  money  when  enthusiastic 
men  are  at  work.     I  take  off  my  hat  to  the  Tennessee  Board  of  Health. 

Texas 

The  department  of  public  health  and  vital  statistics  has  its  office  at  Austin. 
The  last  biennial  report  of  the  energetic  state  health  officer  shows  that  the 
work  is  divided  into  four  departments,  sanitation,  vital  statistics,  pure  food, 
and  quarantine.  Each  branch  seems  to  be  very  active  and  two  hundred  and 
eighteen  of  the  two  hundred  and  twenty-eight  counties  are  organized  as  well 
as  a  large  number  of  the  two  hundred  and  sixty-eight  incorporated  cities  and 
towns.  Some  of  the  state  departments  in  small  eastern  states  would  get  a 
congested  chill  if  they  had  so  many  counties  to  look  after.  Texas  is  a  wonder- 
ful state  and  the  department  must  look  after  the  northern  diseases  as  well  as 
the  tropical  yellow  fever  through  its  "  flying  squadrons  "  that  go  gunning 
for  the  elusive  mosquito  in  the  south  of  the  state  and  bury  frozen  cattle  in  the 
north.  The  department  is  doing  a  good  thing  in  promoting  a  uniform  muni- 
cipal sanitary  code.  The  state  follows  the  uniform  maritime  quarantine 
regulations  of  the  gulf  states,  and  has  a  good  working  arrangement  with  the 
Mexican  health  officials  and  the  Public  Health  and  Marine  Hospital  Service 
charged  with  maritime  and  border  quarantine. 

The  quarantine  regulations  and  vital  statistics  reports  are  reasonable  and, 
considering  the  size  of  the  state,  seem  to  be  fairly  effective.  Many  lines  of 
work  are  being  undertaken,  but  probably  the  most  individual  advance  is  the 
exceedingly  good  regulations  governing  the  sanitation  of  public  buildings, 
railway  coaches,  and  sleeping  cars. 

The  Texas  Anti-Tuberculosis  Association  is  working  in  conjunction  with 
the  state  department,  and  issues  excellent  folders  for  public  instruction. 

Utah 

The  Utah  State  Board  of  Health  transacts  its  business  from  the  office  of 
the  f  ecretary  and  state  registrar  of  vital  statistics  at  Salt  Lake  City.  The  board 
has  a  revised  edition  of  its  health  laws  in  press,  but  the  edition  of  1904  shows 
that  Utah  has  a  board  organized  along  modern  lines.  Since  that  date,  the 
legislature  has  provided  for  a  very  full  registration  of  vital  statistics  much  upon 
the  Pennsylvania  plan,  the  improvement  of  quarantine  and  disinfection  rules, 
and  the  reporting  of  tuberculosis.  The  rules  cover  even  gonorrhoea  and 
syphilis,  although  they  are  not  mandatory  as  to  reporting  them.  The  state 
laws  require  full  county  and  municipal  organization  and  specify  many  things, 
such  as  plumbing  inspection,  the  abatement  of  specified  nuisances,  food  in- 
spection, etc.,  that  are  required  of  local  authorities.  Nuisances  are  well 
defined,  animal  diseases  are  regulated,  corporations  are  regulated,  and  many 
things  done  not  found  in  the  codes  of  older  states. 


206  HYGIENE 

Strange  to  isay,  the  legislature  passed,  over  the  governor's  veto,  "  An  act 
to  prevent  compulsory  vaccination  and  to  prevent  vaccination  being  made  a 
condition  precedent  to  entering  the  public  schools  of  Utah." 

Utah  has  a  state  chemist,  a  dairy  and  food  commissioner  under  rules 
paralleling  those  of  the  federal  statute,  a  state  board  of  barbers  v^ho  enforce 
sanitation,  and  a  rigid  pharmacy  law.  Proprietors  of  drug  stores  are  respon- 
sible for  the  quality  and  purity  of  all  but  package  goods  and  the  U.  S.  P. 
is  the  basis  of  purity.  Substitution  is  punishable  and  the  sale  of  poisons  is 
strictly  regulated. 

The  board  has  issued  some  excellent  circulars. 


Vermont 

It  is  quite  a  task  to  go  through  the  literature  supplied  by  the  Vermont 
State  Board  of  Health,  as  it  is  so  voluminous.  The  offices  are  at  Concord  and 
an  old  state  like  this  gradually  develops  the  several  lines  of  sanitation  very 
much  in  detail.  The  regulations  of  this  board  are  well  tested  and  cover  so 
much  ground  that  we  will  refer  to  the  work  of  this  state  in  the  several  chapters 
rather  than  attempt  to  give  details  here. 

The  state  is  well  organized  and  the  regulations  are  of  a  practical  char- 
acter. The  circulars  upon  contagious  disease  and  the  other  public  literature 
is  excellent.  The  bulletin  is  issued  quarterly  and  shows  that  the  state  labora- 
tory of  hygiene  is  doing  research  and  practical  work  of  a  high  order  and  that 
the  work  of  the  state  is  well  manned. 


Virginia 

Since  July,  1908,  Virginia  has  had  a  department  of  health  under  the 
guidance  of  a  commissioner  of  health.  In  consequence,  most  of  the  laws  and 
regulations  are  new  and  along  modern  lines.  The  board  consists  of  twelve 
members  and  the  commissioner  must  be  a  trained  man.  He  has  charge  of 
the  laboratory  and  public  lectures  and  demonstrations,  and  is  backed  by 
fairly  large  appropriations  and  a  good  code  of  laws  and  regulations.  In  the 
counties,  the  medical  societies  recommend  three  physicians  for  health  officers. 
The  regulations  under  which  local  boards  do  their  work  are  thoroughly  up  to 
date  and  embrace  everything  liable  to  be  needed  to  enforce  sanitary  measures 
of  all  kinds. 

The  execution  of  the  pure  food  law  is  incumbent  upon  the  dair}-  and  food 
commissioners  of  the  department  of  agriculture  and  immigration.  The  pure 
food  laws  of  the  state  are  elaborate  and  the  problems  involved  are  studied 
much  in  detail.  An  aggressive  campaign  against  tuberculosis  is  being  waged 
and  a  state  sanitarium  is  to  be  established.  Diphtheria  antitoxin  is  supplied 
at  a  very  much  reduced  rate  and  standard  fumigating  outfits  are  supplied  at 
cost.  Laboratory  examinations  are  made  free  of  cost  and  a  good  work  is 
being  done. 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH 


207 


There  is  one  great  weakness  and  that  is  the  lack  of  adequate  provision 
for  the  collection  and  tabulation  of  vital  statistics.  The  Virginia  Health 
Bulletin,  entered  as  second-class  matter,  is  one  of  the  best  publications  of  its 
kind  and  employs  an  artist  with  a  very  vivid  imagination,  as  witness  the 
following  reproductions: 


Tour  Turn  Nextf 


How  High  is  the  Wall  in  Tour  Townt 

Washington 


The  state  board  of  health  and  bureau  of  vital  statistics  has  offices  at 
Seattle  and  is  operating  under  brief  but  well-drawn  laws,  fortified  by  legal  tests 
and  opinions  of  the  attorney  general.     The  recently  adjourned  legislature 


208  HYGIENE 

has  added  some  very  good  features  in  the  Hne  of  epidemiological  work.  The 
laws  for  county  boards  and  the  collection  of  vital  statistics  are  the  bases  for 
excellent  service  in  these  directions.  The  bacteriological  laboratory  has  been 
called  to  do  a  great  deal  of  diagnostic  work,  especially  as  regards  typhoid, 
diphtheria,  and  bubonic  plague.  Some  interesting  data  are  given  in  the  last 
biennial  report  upon  Kohlen-oxide  gas  fumigation  and  other  means  for  dis- 
posing of  infected  rats.  The  sanitary  engineer  of  the  board  is  urging  the 
absolute  exclusion  of  sewage  from  the  waterways  of  the  state. 

West  Virginia 

This  state  has  the  offices  of  its  board  at  Wheeling  and  is  organized  for 
the  usual  lines  of  work,  and  its  law  provides  for  county  and  municipal  organi- 
zations. 


The  Hemisphere  of  Oub  Health  Work 


Wisconsin 


The  state  board  of  health  and  department  of  vital  statistics  is  located  at 
Madison.  This  board  is  organized  to  carry  out  the  general  purposes  of  state 
work,  but  emphasis  is  laid  upon  its  functions  as  advisory  to  the  local  boards. 
In  this  it  differs  from  some  other  boards  that  desire  to  centralize  power  in 
themselves  and  make  the  local  boards  quite  subservient  to  them.  In  giving 
practical  application  to  this  basis  of  work,  the  local  boards  are  unusually 
well  organized  and  the  regulations  controlling  them  are  so  admirable  that 
some  space  is  given  to  them  in  Chapter  XL 

The  state  board  retains  the  right  to  promulgate  rules  that  are  binding  in 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  209 

effect  and  have  the  force  of  law  and  make  uniform  the  administration  of  local 
boards.  The  rules  of  quarantine  and  matters  in  general  regulated  by  the 
sanitary  authorities,  are  fairly  rigid.  A  most  excellent  addition  to  the  code 
was  made  in  1907,  and  provides  that  when  a  council  fails  to  appoint  a  local 
board  of  health  the  state  board  will  make  such  appointments  and  charge  up 
the  expense  to  the  village,  borough,  or  city.  There  are  rigid  rules  as  to  tuber- 
cular cases  in  cars  and  conveyances  and  conductors  on  trains  have  the  power 
of  constables  to  enforce  health  regulations. 

A  state  laboratory  is  maintained,  but  accepts  specimens  only  from  health 
officers,  and  it  does  not  undertake  to  make  diagnoses  except  as  may  be  needed 
in  the  work  of  public  hygiene  and  sanitation. 

Wyoming 

The  state  board  of  health  does  not  report  anything  except  meager  pro- 
visions for  state  medicine,  but  a  private  letter  received  from  Cheyenne  informs 
me  that  the  secretary  of  the  board  has  his  work  very  much  at  heart. 

Conclusions 

Having  reviewed  the  work  of  the  states,  it  may  not  be  amiss  to  draw  some 
conclusions.  The  reader  will  have  observed  that  we  discussed  the  general 
features  of  state  medicine  upon  the  basis  of  the  more  recent  forms  of  organi- 
zation such  as  that  of  Pennsylvania.  This  is  not  meant  in  disparagement  of 
other  states.  In  fact,  one  would  be  blind  to  many  things  were  he  to  fail  to 
recognize  the  fact  that  this  more  recent  form  of  powerful  organization  is,  as 
yet,  in  an  experimental  stage  and  may  need  modification.  It  may  strike  a 
Northern  man  as  strange  that  the  South  was  the  first  to  recognize  adequately  the 
need  for  state  quarantine.  Yellow  fever  did  that  for  the  South  and  I  well 
remember  the  time  when  Northern  people  were  free  with  criticism  of  the  South 
for  the  alleged  cruelties  of  its  quarantine  regulations.  In  that  day,  the 
Southern  states  left  the  details  of  quarantine  to  the  medical  societies  to  a 
degree  unheard  of  now,  except  as  to  the  remnants  of  the  old  rules,  still  in  force 
in  some  ofthe  Southern  states,  Alabama  being  an  example.  It  worked  out 
fairly  well,  and  I  am  not  quite  sure  but  that  the  medical  profession  and  the 
medical  societies  are  unduly  neglected  in  the  present  administration  of  sani- 
tary affairs. 

The  New  England  states  are  among  the  oldest  as  settlements  and  as 
state  sanitarians,  and  I  believe  we  have  considerable  to  learn  from  them.  A 
review  of  their  literature  gives  one  the  impression  that  the  laws  there  in  force 
are  well  tried  and  fit  the  people  well.  The  humanities  are  well  worked  out 
there  and  both  the  New  England  states  and  the  Southern  states  seem  to  be 
more  actually  in  contact  with  the  masses  of  the  people  and  their  needs  than 
are  the  states  with  a  more  modern  code.  As  a  matter  of  fact,  some  of  these 
states  issue  literature  more  calculated  to  reach  the  people  and  be  read  by  them 
than  is  that  printed  by  some  of  the  states  with  greater  legal  powers  for  their 
boards. 

Such  states  as  Maine,  Vermont,  Virginia,  and  Louisiana  issue  ideal 
literature  for  public  education  along  sanitary  lines,  and  one  cannot  but  feel 


210  HYGIENE 

that  they  realize  that  it  is  difficult  to  effectively  legislate  ahead  of  public 
opinion.  Candor  compels  the  admission  that  one  sees  some  strange  contrasts 
in  the  South.  I  was  down  in  a  certain  Southern  state  a  few  days  ago  and  noted 
how  particular  they  were  to  watch  the  "  jim  crow  cars  "  and  how  filthy 
the  white  man's  smoking  cars  were.  Furthermore,  the  Northern  passengers 
were  the  more  offended  by  contact  with  colored  persons.  It  also  looked 
funny  to  see  signs  on  every  corner  prohibiting  expectoration  when  the  streets 
and  open  gutters  were  a  reeking  abomination.  Even  in  the  District  of  Col- 
umbia, where  the  regulations  are  ideal,  I  have  recently  seen  conditions  that 
were  far  from  ideal.  But  when  I  contrast  Southern  conditions  of  the  present 
with  what  used  to  be  there,  I  feel  that  they  are  making  greater  progress  in 
sanitation  than  are  some  Northern  towns  and  states  I  could  name.  The 
doctors  in  the  South  are  a  whole-souled  set  of  good  fellows  and  would  not  sub- 
mit to  the  starchy  legislation  of  some  of  the  Northern  cities.  The  health  officer 
soon  learns  that  he  must  be  a  good  fellow  too,  or  there  is  a  change  of  admin- 
istration. And,  after  all,  a  mere  general  practitioner  like  myself  is  a  little 
inclined  to  the  view  that  the  Southern  people  do  some  things  with  a  regard  to 
human  nature  that  is  wise  in  the  long  run  and  that  brings  results. 

And  it  might  also  strike  a  Northern  man  as  strange  that  the  Southern 
boards  have  some  splendid  laboratories  and  are  working  out  the  scientific 
end  of  sanitation  in  a  way  some  Northern  states  might  very  profitably  copy. 
Some  of  our  most  talented  investigators  are  in  the  South  and  it  is  to  be  noted 
that  the  therapeutic  nihilist  is  "  persona  non  grata  "  down  there  where  they 
are  apt  to  need  real  doctors  and  need  them  quickly.  The  doctor  is  really 
respected  in  Dixie  Land. 

In  Chapter  XI,  I  took  occasion  to  draw  a  contrast  between  the  states  of 
Indiana  and  Wisconsin  as  regards  some  of  the  legal  phases  of  the  work. 
Wisconsin  and  Michigan  are  states  having  advisory  powers,  and  yet  a  modern 
form  of  organization.  I  know  something  about  those  states  and  particu- 
larly Michigan,  There  you  will  find  the  state  board  conducting  one  of  the 
most  effective  lines  of  popular  education  in  the  United  States.  The  Michigan 
bulletins  are  a  model  and  the  authorities  realize  that  popular  support  is 
imperative,  and  it  keeps  the  board  keyed  up  to  a  sense  of  the  due  proportion 
of  things.  It  would  be  manifestly  unfair  for  me  to  criticise  the  work  of  any 
board  with  which  I  was  not  intimately  familiar,  and  I  am  absolutely  not  in 
position  to  condemn  the  form  of  organization  of  the  small  coterie  of  boards 
claiming  practically  legislative  functions,  but  one  can  see  advantages  in  the 
other  form,  and  I  feel  justified  in  directing  attention  to  Wisconsin  and  Michi- 
gan as  affording  illustrations  of  the  fact  that  it  is  not  essential  to  vest  large 
special  powers  in  a  state  board  of  health  to  enable  it  to  do  a  splendid  work. 
In  relation  to  this,  permit  me  to  call  attention  to  the  following  from  the 
Journal  of  the  American  Medical  Association,  May  1,  1909: 

THE  WORK  OF  BOARDS  OF  HEALTH 

Dr.  George  A.  Soper,  in  the  Popular  Science  Monthly,  March,  1909,  considers  the 
powers  and  relations  of  boards  of  health  from  a  popular  viewpoint.  He  notes  the  com- 
bination of  legislative,  executive,  and,  sometimes,  judicial  powers  granted  to  such 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  211 

boards,  and  while  admitting  that  extensive  authority  may  have  been  necessary  in  the 
emergencies  created  by  epidemic  diseases,  he  questions  whether  it  would  not  be  wise, 
in  view  of  the  extension  of  the  field  of  operation  of  health  authorities,  to  limit  their 
powers.  Another  anomaly  in  our  system  is  that  the  highest  health  authority  is  the 
state  to  which  the  municipalities  are  related,  but  there  is  no  national  health  board  to 
correlate  the  action  of  the  various  states. 

The  duties  of  boards  of  health  may  be  defined  as  the  collection  of  vital  statistics, 
the  suppression  of  communicable  diseases,  the  abatement  of  nuisances,  and  the  edu- 
cation of  the  people  in  health  matters.  It  may  properly  be  asked  what  are  to  be  con- 
sidered nuisances.  There  is  danger  that  the  health  board  may  occupy  itself  with  in- 
conveniences of  a  semi-esthetic  nature  to  the  neglect  of  matters  of  more  serious  im- 
portance in  relation  to  health.     Dr.  Soper  says: 

"  There  is  something  incongruous  about  a  board  of  health  conducting  a  crusade 
against  smoke  and  noise,  and  at  the  same  time  allowing  the  streets  to  be  filthy  with  dirt 
and  dust  and  offensive  with  accumulations  of  fermenting  garbage.  Again,  a  great  deal 
of  the  attention  of  health  boards  is  occupied  with  alleged  private  nuisances  which  affect 
comfort,  but  not  health.  The  history  of  every  city  is  a  record  of  more  and  more  strict 
regulations  to  minimize  the  unpleasant  as  well  as  the  insanitary  conditions  of  household 
life." 

In  the  sanitary  education  of  the  public  the  important  aid  given  by  the  press  is 
recognized,  but  it  is  to  be  regretted  that  the  opportunities  for  systematic  school  instruc- 
tion on  these  subjects  are  still  to  a  large  extent  lacking.  "  In  the  campaign  of  sanitary 
education  which  is  going  on  it  is  a  deplorable  fact  that  the  universities  and  colleges  of 
the  United  States  are  singularly  backward.  With  a  few  notable  exceptions,  there  is 
scarcely  a  school  for  higher  education  in  the  United  States  where  a  competent  knowl- 
edge of  hygiene  can  be  obtained.  In  spite  of  the  fact  that  many  of  the  largest  and  most 
prominent  universities  have  had  severe  experiences  with  typhoid,  they  have  been 
exceedingly  slow  in  providing  proper  facilities  for  the  teaching  of  hygiene.  One  of  the 
greatest  needs  of  to-day  is  the  want  of  competent  teaching  for  health  officers,  physi- 
cians, engineers,  and  others  who  may  wish  to  obtain  a  complete  and  practical  knowl- 
edge of  their  profession.  In  the  absence  of  suitable  facilities  for  the  education  of  health 
officers  the  United  States  is  decidedly  behind  European  countries." 

The  propriety  of  the  extension  of  the  activity  of  health  boards  into  the  realm  of 
esthetics  may  be  questioned,  but  they  have  been  granted  ample  power.  The  standards 
of  public  health  and  municipal  hygiene  are  continually  growing  higher.  "  First  and 
foremost  among  the  defects  and  needs  of  public  health  administration,"  says  Soper, 
"  must  be  placed  the  want  of  adequate  knowledge  of  the  principles  and  practices  of 
public  health  work  on  the  part  of  officials  having  jurisdiction.  It  is  a  deplorable  fact 
that  special  professional  qualifications  are  not  as  a  rule  required  of  health  officers 
in  the  United  States. 

"  If  there  is  any  department  of  municipal  government  that  should  be  taken  out 
of  politics  and  put  on  a  high  plane  of  professional  efficiency  it  is  public  health  work. 
Generally  in  the  United  States  appointment  on  a  public  health  board  means  a  thank- 
less and  gratuitous  service  performed  for  the  sake  of  the  small  honor  which  is  supposed 
to  go  with  it.  Where  a  salary  is  connected  with  the  position  the  office  is  too  often  a 
reward  of  political  work  rather  than  of  professional  merit. 

Dr.  Soper  is  slightly  in  error,  as  Cornell,  Pennsylvania,  and  Michigan 
Universities  give  such  a  training  as  he  commends,  and  I  have  heard  that  some 
other  institutions  do  so  as  well.  In  general,  he  raises  some  questions  worthy 
of  consideration.     His  statement  as  to  politics  dominating  health  boards  is 


212  HYGIENE 

rather  sweeping,  but  true  of  many  of  them,  and  especially  of  local  boards. 
We  will  discuss  that  later,  but  first  want  to  state  a  side  he  failed  to  touch  upon 
and  that  the  physicians  of  the  land  are  apt  to  forget. 

And  that  raises  the  whole  question  as  regards  boards  with  large  powers 
("  legislative,  executive,  and  sometimes  judicial  ")  and  as  are  instanced  in 
Indiana  and  Pennsylvania.  While  it  is  remarkable  that  the  United  States 
government  has  lived  and  expanded  so  well  under  a  constitution  adopted 
away  back  in  1787,  and  but  slightly  amended  since,  yet  the  fact  remains  that 
many  good  citizens  have  felt  that  the  federal  power  is  too  limited  to  ade- 
quately meet  the  exigencies  of  modern  governmental  communication  and 
treaty  obligations  as  well  as  to  provide  for  certain  common  necessities  as  re- 
gards traffic  between  the  states  and  other  domestic  questions  growing  out  of 
modern  conditions.  As  it  is  brought  home  to  us  doctors,  we  must  realize  that 
there  would  be  no  federal  government  unless  it  had  been  preceded  by  several 
sovereign  states  finding  such  a  governmental  clearing  house  necessary. 
Even  so,  there  can  be  no  federal  department  of  health  without  the  demand  for 
it  by  organizations  within  the  states  needing  it  for  a  common  ground  of  union 
and  exchange.  The  very  fact  that  there  is  not  a  federal  power  adequate  to 
the  accomplishment  of  the  work  of  national  sanitation  has  made  it  necessary 
for  the  states  to  initiate  functions  that,  judicially  considered,  do  not  really  be- 
long to  the  individual  states. 

Naturally,  the  states  arrived  at  differing  conclusions  and  devised  varying 
plans.  And  it  is  well  that  they  did  so  even  as  it  is  well  that  they  put  into  effect 
differing  divorce  laws.  It  is  better  to  try  an  experiment  with  one  state  than 
with  the  whole  nation.  As  it  is,  all  kinds  of  health  organizations  have  been 
tried  out  in  practice  and  Invaluable  data  is  collecting  to  assist  the  federal 
power  to  wisely  initiate  a  national  work  in  due  time.  Indiana  and  Pennsyl- 
vania are  trying  the  plan  of  a  centralized  board.  Naturally,  the  Indiana 
and  Pennsylvania  officials  are  delighted  with  the  success  they  have  achieved, 
but  the  fact  remains  that  no  certain  judicial  basis  yet  exists  for  regarding 
this  plan  as  ideal  for  the  whole  United  States  nor  yet  even  for  Indiana  and 
Pennsylvania.  That  it  is  a  harmonious  and  rational  plan  cannot  admit  of 
doubt,  but  that  it  is  exactly  adapted  to  the  genius  of  all  forms  of  American  law 
and  American  government  cannot  be  determined  until  after  it  is  under  fire 
and  passes  the  scrutiny  of  American  courts  and  proves  itself  acceptable  to 
the  American  people  and,  may  I  add,  the  rank  and  file  of  the  American  med- 
ical profession. 

It  is  an  exceedingly  difficult  matter  to  make  any  law  flexible  enough  to 
cover  the  extremes  of  condition  demanded  by  insanitary  conditions.  From 
a  widespread  pestilence,  constituting  a  national  disaster,  to  the  regulation  of 
little  matters  of  petty  detail  in  sanitation,  is  a  long  stretch  for  any  law  to 
cover.  When  the  nation  is  not  in  position  to  step  in  and  do  the  things  for 
which  a  trained  force  may  be  necessary  any  hour,  it  is  imperative  that  the 
states  delegate  to  some  one  the  authority  to  meet  the  emergency.  But  a 
legislature  cannot  pass  a  law  giving  a  certain  authority  one  day  and  with- 
holding it  the  next  day.     Consequently,  in  order  to  be  ready,  some  of  the 


MICHIGAN    LABORATORY    OF    HYGIENE 
MEDICAL    MISSIONARY    WORK    IN    THE    TROPICS 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  213 

boards  have  powers  necessary  in  time  of  peril,  but  that  might  become  op- 
pressive under  other  circumstances. 

In  the  federal  government  there  are  the  co-ordinate  branches  of  legisla- 
tive, executive,  and  judiciary.  In  time  of  emergency  the  executive  officer 
(the  president)  may  fill  in  the  breach  until  Congress  can  meet  or  until  the 
courts  can  pass  upon  the  matter.  In  the  absence  of  emergency  he  v^ould 
run  the  risk  of  impeachment  if  he  undertook  to  exceed  the  necessary  authority. 
Apply  this  same  reasoning  to  state  boards  of  health,  and  it  is  not  difficult  to 
draw  some  conclusions  that  are  applicable  to  the  case  in  hand. 

While  these  objections  to  a  centralized  board  may  be  considered  as 
academic,  the  plan  of  meeting  objection  by  making  the  governor  and  the 
attorney  general  consulting  members  of  the  board  or  securing  their  sanction 
to  measures,  is  also  academic.  Many  able  publicists  consider  it  as  unsafe 
to  get  far  away  from  the  authority  of  the  courts  in  anything,  and  they  claim 
that  the  courts  are  the  greatest  conservators  of  our  liberties.  W  hile  that  may 
all  be  true  enough,  yet  we  know  that  courts  are  very  finite  indeed  and  look 
quite  as  ridiculous  to  doctors  sometimes  as  the  doctors  look  to  the  learned 
court.  Neither  understands  the  other  and  the  plan  of  placing  sanitary 
measures  under  the  review  of  the  court  would  result  in  a  large  mortality  before 
anything  was  done.  The  law,  as  administered  by  our  sluggish  courts,  is 
utterly  inadequate  to  meet  the  sanitary  necesssities  of  the  twentieth  century. 
Consequently,  something  had  to  be  done  and  the  most  natural  thing  to  do 
was  to  do  just  what  the  government  has  done  in  constructing  the  Panama 
Canal,  turn  from  the  civilian  to  the  soldier.  That  is  just  what  has  happened  in 
sanitation.  It  is  in  the  armies  and  navies  that  many  of  these  questions  have 
been  worked  out  and  the  most  effective  federal  work  is  that  done  by  the  Public 
Health  and  Marine  Hospital  Service.  Next  to  it,  comes  the  surgeon  general's 
office,  and  it  impresses  me  that  food  and  drug  work  and  other  lines  of  federal 
sanitation  will  ultimately  be  under  a  semi-military  regime.  It  is  almost  neces- 
sary that  it  should  be  so  and  we  may  just  as  well  face  that  fact  now  as  after 
awhile. 

Despite  any  objections  we  may  urge  and  whether  we  like  it  or  no,  the 
signs  of  the  times  are  that  a  disciplined  sanitary  service  absolutely  divorced 
from  politics  must  be  maintained  by  every  respectable  government.  If  the 
civil  code  does  not  provide  for  it,  so  much  the  worse  for  the  civil  code  and 
musty  legal  precedent. 

The  medical  profession  is  getting  rid  of  empiricism  and  convention  and 
if  the  American  legal  profession  does  not  wake  up  to  the  times  and  follow  the 
example,  so  that  necessary  legal  decisions  can  be  reached  vastly  quicker  than 
they  are  to-day,  the  great  twentieth  century  will  roll  on  without  consulting 
them  very  much  and  find  a  new  wa}  of  doing  things.  The  sanitarians  have 
already  found  it  and  the  new  way  is  here  to  stay.  This  is  not  said  to  detract 
from  the  courts,  but  the  courts  are  too  slow  to  meet  the  emergencies  of  epi- 
demics and  other  sanitary  problems.  When  a  federal  department  of  health 
get  under  headway  and  after  it  has  shaken  off  the  barnacles  of  bureau  poli- 
ticians that  will  hedge  it  about  at  first,  it  is  likely  that  the  objections  to  the 


214  HYGIENE 

centralized  form  of  state  department  will  be  removed  and  the  powers  of  the 
boards  will  be  limited  and  their  plans  and  administration  harmonized. 

Meanwhile,  we  must  be  patient.  It  is  probably  true  enough,  as  Dr.  Soper 
intimated,  that  the  centralized  boards  are  given  too  much  power.  But  the 
practical  fact  remains  that  state  sanitation  was  in  so  bad  a  way  throughout 
most  of  the  states  that  something  radical  was  imperative,  and  we  must  not 
view  the  question  in  the  light  of  old  English  legal  precedent  and  quibble  over 
trifles  in  the  face  of  death  and  disease.  I  do  not  pretend  to  be  a  lawyer,  but  I 
have  talked  with  many  of  them  over  this  matter,  and  have  yet  to  find  one  that 
can  view  the  question  in  the  larger  aspects  demanded.  I  have  no  doubt 
there  are  many  such  men  in  the  profession  and  the  sanitarians  will  align 
themselves  with  them  and  the  very  involved  questions  of  sanitary  administra- 
tion will  be  well  worked  out.  Meanwhile,  let  no  state  or  no  board  conclude 
it  has  the  only  right  and  proper  plan.  Furthermore,  it  becomes  state  health 
officials  to  be  a  little  modest  in  the  routine  use  of  power  conferred  upon  them, 
for  the  sole  purpose  of  meeting  emergencies  for  the  public  good.  Undue  display 
of  power  simply  aids  the  adversaries  of  sanitation. 

As  things  are  at  present,  boards  like  those  of  Indiana  and  Pennsylvania 
have  taken  pretty  advanced  ground,  and  possibly  their  position  may  not  be 
wholly  tenable.  On  the  other  hand,  it  would  not  seem  to  be  wise  to  take  away 
their  power  to  act  in  emergency.  They  might  be  more  advisory  in  their 
functions  as  regards  their  relations  with  counties  and  municipalities  and  be 
more  subject  to  legal  review.  Certainly,  they  have  been  doing  a  good  work, 
and  any  criticism  attaching  to  the  plan  under  which  they  operate  has  very 
little  force  when  applied  to  what  they  have  actually  done,  and  that  is  the  record 
by  which  they  stand  or  fall. 

Western  legislatures  seem  to  be  in  a  hurry  to  get  through  with  sanitary 
legislation,  but  exceedingly  willing  to  do  those  tangible  things  required  for 
adequate  quarantine  and  public  instruction.  The  campaigns  of  education 
and  the  codes  of  law  in  the  Western  states  are  up  to  date,  but  there  is  a  little 
neglect  of  such  matters  as  are  found  in  the  older  states  so  far  as  relates  to 
factory  inspection,  industrial  sanitation,  and  what  may  be  called  the  humani- 
ties. This  will  correct  itself  and  all  that  is  needed  is  simple  addition  to  their 
already  excellent  laws.  I  cannot  but  admire  the  Western  horror  of  slums  and 
outside  of  a  few  of  the  larger  cities,  one  finds  few  slums  in  the  West.  Here  in 
the  East,  hosts  of  towns  where  land  is  cheap  have  abominable  alleys  teeming 
with  shanties,  wretchedly  poor  people  and  tuberculosis.  There  is  no  excuse 
except  that  of  greed  for  such  conditions.  An  up  to  date  Western  town  seldom 
allows  such  conditions  and  the  West  is  right.  People  live  more  outdoors  in 
the  West  and  build  better  houses,  placed  further  apart  than  does  the  average 
Eastern  town.  Consequently,  sanitation  is  a  somewhat  easier  task,  except 
in  the  foreign  colonies  not  yet  Americanized.  An  examination  of  the  litera- 
ture of  the  Western  boards  convinces  the  reader  that  the  West  is  doing  a 
thoroughly  efficient  work  in  public  sanitation. 

As  to  Dr.  Soper's  charge  that  politics  is  too  much  of  a  factor,  my  obser- 
vation is  that  the  higher  officials  in  health  administration  are  as  clean  and 
altruistic  a  body  of  men  as  one  will  find  anywhere  and  are  a  credit  to  the 


STATE  DEPARTMENTS  —  BOARDS  OF  HEALTH  215 

country.  Unfortunately,  state  boards  of  health  are  obliged  to  go  to  legis- 
latures and  the  political  powers  that  be  for  the  necessary  appropriations.  It 
is  unnecessary  to  enter  into  details,  but  the  end  result  is  that  many  subsidiary 
appointments  are  dominated  by  the  more  or  less  creditable  politician.  It  is 
unfair  to  charge  this  against  the  state  boards,  for  I  am  quite  assured  that  no 
body  of  men  are  more  opposed  to  political  meddling  than  are  the  health  offi- 
cials of  the  states.  As  a  matter  of  fact,  they  seldom  have  any  voice  in  the 
appointment  of  local  boards.  As  to  political  conditions  in  city  and  tov^nship 
and  other  local  boards,  the  general  practitioner  of  medicine  is  in  position  to 
judge  for  himself  and  I  do  not  care  to  discuss  it  here  except  to  say  that  condi- 
tions are  improving. 

There  is  one  unfortunate  condition  that  should  be  corrected.  Profes- 
sional sanitarians  gravitate  so  easily  into  a  class  feeling  and  take  an  attitude 
apart  from  their  fellows  in  practice,  while  the  latter  class  are  just  as  apt  to 
regard  the  former  with  a  certain  degree  of  suspicion  and  distrust.  This  is 
absolutely  unwarranted  upon  both  sides.  In  collecting  data  for  this  book,  I 
have  been  surprised  to  find  how  little  the  state  boards  knew  about  each  other 
and  how  little  real  knowledge  of  their  work  exists  among  the  officials  in  Wash- 
ington. We  need  to  get  acquainted  with  each  other  and  inaugurate  a  "  get 
together  campaign  "  for  the  good  of  all  concerned. 

Finally,  after  my  investigations  of  state  boards,  I  can  truthfully  say  that 
I  am  proud  of  my  country  and  of  the  grand  work  being  done  by  so  many  states, 
north,  east,  south,  and  west,  under  the  twining  flags,  "  old  glory  "  and  the 
red  cross. 


Chapter  X 
A  PROPOSED  FEDERAL  BUREAU  OF  HEALTH* 

What  the  Government  at  Washington  is  now  doing  —  What  it  might  do  —  What 
such  a  bureau  or  department  of  health  might  do  for  the  general  good  of  medicine 
and  sanitation  —  The  importance  of  international  hygiene  as  shown  in  Cuba  and  the 
Canal  Zone  —  The  Army  and  Navy  and  public  health  —  The  hygiene  of  interstate 
and  international  commerce. 

THE  health  of  our  people  is  now  recognized  to  be  largely  a  responsibility 
of  the  municipality,  state,  or  nation,  the  individual  is  so  often  powerless 
to  protect  himself  against  his  neighbors  and  his  environments.  Ever}'- 
body'shealth  is  nobody's  business.  The  question  of  the  preservation  of  public 
health  has  become  each  year  more  important.  The  length  of  life  is  increasing 
wherever  sanitary  science  and  preventive  medicine  are  applied.  Thisis  illus- 
trated by  the  case  in  India,  where  nothing  is  done  and  the  average  has  not 
increased  above  twenty-three  and  a  half  years,  and  in  Prussia  the  home  of 
preventive  medicine  where  the  average  life  is  forty-seven  and  is  still  lengthen- 
ing. "  From  data  collected  it  is  found  that  fifteen  years  at  least  could  be  at 
once  added  to  the  average  human  life  by  applying  the  science  of  preventing 
disease.  More  than  half  of  this  additional  life  would  come  from  the  pre- 
vention of  tuberculosis,  typhoid  fever,  and  five  other  diseases,  the  prevention 
of  which  could  be  accomplished  by  pure  air,  pure  water,  and  pure  milk." 

As  a  nation  we  have  no  comprehensive  health  organization.  No  mem- 
ber of  the  Cabinet  of  the  President  of  the  United  States  has  any  direct  respon- 
sibility for  the  health  and  life  of  our  people,  which  is  so  much  more  important 
than  mere  property  interests.  "  The  health  of  our  pigs  has  representation 
in  the  Cabinet,  but  not  our  children."  Our  only  federal  guardianship  is 
vested  in  the  United  States  Public  Health  and  Marine  Hospital  Service,  under 
the  control  of  the  Treasury  Department.  What  particular  interest  the  Treas- 
ury Department  can  have  in  the  public  health  is  hard  to  conceive.  What  we 
need  is  a  national  bureau  of  health.  We  are  the  only  great  civilized  nation 
without  such  a  department.  Several  branches  of  the  government  have  to  do 
more  or  less  with  matters  of  public  health,  and  are  doing  excellent  work. 
The  Department  of  Agriculture  must  pass  judgment  on  foods,  drugs,  and 
medicine.  The  Bureau  of  Vital  Statistics  is  under  the  Department  of  Com- 
merce and  Labor.  The  Public  Health  and  Marine  Hospital  Serv'ice  is  under 
the  Secretary  of  the  Treasury,  who  is  the  chief  medical  officer  of  the  United 
States.  The  Department  of  Interior  has  charge  of  the  National  Elemosy- 
nary  Institutions,  all  of  them  public  health  agencies.  They  are  all  doing 
good  work,  but  they  are  inadequate,  scattered,  and  unorganized,  and  in  that 
degree  are  inefficient. 

The  movement  abroad  now  is  to  take  the  several  bureaus,  exercising 
health  functions  that  are  now  scattered  through  the  Treasury,  Interior,  and 
Agriculture   Departments,  and   centralize  them  all   in   one   department  of 

*By  J.  B.  McAlister,  A.M.,  M.D. 


PROPOSED  FEDERAL  BUREAU  OF  HEALTH        217 

health,  which  would  be  of  service  worthy  of  the  nation.  There  is  a  wide- 
spread and  growing  movement  throughout  the  United  States  for  the  creation 
of  this  new  department.  The  campaign  for  the  establishment  of  a  national 
bureau  of  public  health  has  been  carried  on  by  the  Committee  of  One  Hundred 
of  the  American  Association  for  the  Advancement  of  Science,  and  recom- 
mended by  the  American  Medical  Association  as  long  ago  as  1871;  and  at 
intervals  during  the  succeeding  years  it  has  been  a  live  subject  before  this  asso- 
ciation. At  present  the  movement  seems  to  be  making  towards  success. 
First  the  Ohio  republican  platform  of  1908,  and  later  the  platform  of  both 
parties  in  the  national  campaign  declared  for  a  national  public  health 
department.  President  Taft  in  his  message  at  the  opening  of  Congress, 
December  7,  1909,  says,  "  There  seems  to  be  no  reason  why  all  the  bureaus 
and  offices  in  the  general  government,  which  have  to  do  with  the  public  health 
or  the  subjects  akin  thereto  should  not  be  united  in  a  bureau  to  be  called  the 
Bureau  of  Public  Health."  In  a  recent  speech.  President  Taft  also  says: 
"  How  near  this  movement  will  come  to  accomplishing  the  complete  purpose 
of  its  promoters  only  the  national  health  can  tell.  Certainly  the  economy 
of  the  union  of  all  health  agencies  of  the  national  government  in  one  bureau 
or  department  is  wise."  Former  President  Roosevelt  gave  this  movement 
his  cordial  support.  Professor  Russel  H.  Chittenden,  who  strongly  supports 
the  movement,  says,  "The  purpose  of  our  movement  is  of  course  not  merely 
the  establishment  of  a  national  bureau  of  health.  That  step  itself  is  merely 
a  means  to  an  end.  The  end  is  the  elevation  of  the  health  of  the  American 
people." 

Such  a  department  of  health  at  Washington,  with  the  power  and  wealth 
of  the  government  back  of  it,  with  laboratories  the  equal  of  any  in  the  world, 
and  with  a  corps  of  research  workers,  the  peers  of  any  in  the  world,  engaged 
continually  in  searching  out  the  cause  and  prevention  of  disease,  would 
make  it  equal  to  any  function  of  the  government.  There  would  be  a  bureau 
of  vital  statistics,  which  in  this  country  is  an  infant  science.  Yet  it  is  the  very 
basis  of  any  attempt  to  better  the  general  health.  It  would  gather  data  as  to 
the  location  and  cause  of  all  sickness  and  every  death  in  the  United  States, 
and  would  tabulate  and  disseminate  the  knowledge  thus  obtained  with  a  view 
of  preventing  other  sickness  and  death.  Only  fifteen  states,  representing 
forty-eight  per  cent  of  our  population,  records  all  deaths  and  forbids  burial 
without  a  legal  permit  giving  the  cause  of  death  and  other  details.  In  some 
states  there  is  no  such  thing  as  general  registration  of  births,  school  attendance, 
factory  employment,  etc.  "  It  is  curious  to  note  that  Uruguay  in  its  official 
report  of  statistics  regrets  its  inability  to  draw  satisfactory  conclusions  from 
the  United  States  of  America,  because  the  nation  has  not  yet  attained  to  any 
scientific  method  of  treating  the  subject."  A  national  department  of  health 
could  remove  this  reproach,  and  without  accurately  compiled  statistics  sani- 
tary calculations  will  be  mere  guesswork. 

With  such  a  department  preventive  diseases  could  be  still  further  pre- 
vented to  the  incalculable  benefit  of  the  people.  Suppose  the  power  of  the 
government  was  exerted  to  check  the  ravages  of  tuberculosis  in  the  United 
States.     One  hundred  and  fifty  thousand  persons  die  annually  of  tuberculosis, 


218  HYGIENE 

three  fourths  of  which  could  be  avoided.  The  movement  against  this  disease 
is  now  world  wide  in  extent,  by  private  societies  and  municipalities,  and  a  few 
state  governments;  but  with  the  guide  of  the  government,  in  a  campaign  of 
education  and  sanitation,  who  can  imagine  the  results  that  would  accrue  ? 

Now,  consider  the  poison  in  water  supplies,  and  the  prevalence  of  typhoid 
fever,  due  to  the  almost  total  lack  of  sanitary  supervision  over  streams  that 
are  sources  of  water  supplies.  Even  though  certain  states  do  their  duty 
many  streams  are  interstate  in  their  course,  making  the  pollution  of  the 
stream  a  national  problem.  Of  what  avail  to  police  one  side  of  a  stream  if 
you  do  not  control  both  sides  and  the  source  as  well.  Lake  Champlain,  for 
instance,  is  protected  on  the  New  York  side  and  contaminated  on  the  Vermont 
shore.  It  took  an  epidemic  of  typhoid  fever  to  teach  Ithaca  and  Scranton  that 
they  must  not  drink  filth.  Any  state  can  prohibit  the  pollution  of  water  sup- 
plies in  its  borders,  but  cannot  prevent  other  states  emptying  its  sewerage 
into  streams  which  may  be  a  water  supply  in  another  state.  The  indifference 
of  our  people  to  the  pollution  of  our  rivers  has  made  it  urgent  that  their 
supervision  should  be  the  duty  of  a  federal  department  of  health.  The 
national  government  should  enact  suitable  legislation  providing  against 
pollution  of  the  interstate  streams. 

The  federal  government  should  provide  for  more  investigation  in  health 
matters  and  the  education  of  the  public  concerning  preventable  disease.  If 
diseases  are  preventable,  why  are  they  not  prevented  ?  Some  one  has  said, 
"  For  every  death  from  typhoid  fever,  some  one  should  be  hung."  So  the 
public  should  be  aroused  to  hold  public  health  officials  responsible  for  health 
conditions.  A  federal  health  bureau  could  co-operate  with  state  and  muni- 
cipal authorities  in  checking  epidemics,  in  the  enforcement  of  pure  food  laws 
and  meat  inspection;  the  education  of  the  people  in  both  public  and  private 
hygiene;  encourage  medical  investigation  and  establish  a  national  medical 
practice  act  to  raise  the  standard  of  medicine  to  the  welfare  of  the  people;  and 
improve  the  efficiency  of  our  state  and  national  health  services.  "  A  poultry 
raiser  or  a  cattleman  or  a  farmer  can  secure  scientific  information  to  guide 
him  in  his  selection  of  fowl  or  stock  or  seed,  by  applying  to  the  government  at 
Washington;  but  information  on  how  to  raise  children  has  up  to  this  time 
been  neglected  by  our  government." 

We  have  three  bodies  in  the  national  line  of  defense  against  disease, 
the  Public  Health  and  Marine  Hospital  Service,  the  Medical  Corps  of  the 
Army  and  Navy.  The  first  protects  our  quarantines,  excludes  emigrants 
with  infectious  disease,  and  assists  in  epidemics  when  called  upon.  It  assisted 
New  Orleans  to  eliminate  yellow  fever  and  San  Francisco  to  rid  itself  of  the 
bubonic  plague.  Each  year  it  treats  fifty  thousand  seamen,  and  maintains  a 
large  number  of  hospital  relief  stations  and  conducts  a  well-equipped  hygienic 
laboratory. 

The  work  of  the  army  medical  corps  in  our  insular  possessions  and  in  the 
Canal  Zone  is  only  an  example  of  the  efficiency  of  a  national  bureau,  with  the 
power  of  the  government  back  of  it.  The  sanitary  reforms  introduced  into 
Cuba  stand  out  as  noble  monuments  to  the  American  Medical  Corps.  In 
Havana,  the  hotbed  of  insanitary  conditions,  with  yellow  fever  epidemic  for 


PROPOSED  FEDERAL  BUREAU  OF  HEALTH        219 

two  centuries,  the  introduction  of  modern  sanitary  measures  reduced  the  death 
rate  of  disease,  except  yellow  fever.  General  sanitary  measures  had  no 
effect  upon  yellow  fever  until  acting  upon  the  theory  that  the  stegomyia  mos- 
quito was  the  only  means  of  transmitting  yellow  fever  and  measures  were 
taken  for  the  destruction  of  the  mosquito  was  yellow  fever  eradicated.  When 
the  American  army  took  charge  of  the  health  department  of  Havana  the  death 
rate  was  21,223  per  year.  When  it  relinquished  authority  the  death  rate  was 
5,720  per  year.  Smallpox  occurring  epidemic  annually  is  now  as  rare  as  in  an 
American  city.  The  army  stamped  out  yellow  fever  in  its  greatest  stronghold 
and  has  demonstrated  a  system  by  which  yellow  fever  can  certainly  be  con- 
trolled without  interference  to  commerce  and  untold  financial  loss  to  both 
Havana  and  the  United  States,  as  formerly.  "It  has  been  estimated  that  the 
yellow  fever  epidemic  of  1878  invaded  132  towns,  caused  a  mortality  of  15,954 
persons,  and  that  the  pecuniary  loss  in  this  country  was  not  less  than  ^100,- 
000,000  in  gold.— Dr.  Walter  Wyman." 

The  work  of  sanitation  in  the  Canal  Zone  is  equally  brilliant.  The 
efficient  work  of  Colonel  Gorgas  has  rendered  the  isthmus  a  safe  place  of  habi- 
tation. The  yellow  fever  has  been  effectually  stamped  out  and  malaria 
reduced  to  a  minimum.  Health  conditions  compare  favorably  to  those  which 
obtain  in  this  country,  among  a  similar  body  of  men,  and  the  death  rate  among 
the  women  and  children  of  the  families  of  these  men  about  the  same  as  in  this 
country.  Careful  hygiene  and  systematic  sanitation  as  enforced  by  our  army 
has  stripped  the  once  greatly  dreaded  isthmus  of  Panama  of  its  terrors  and 
rendered  it  perfectly  safe  for  residence  and  occupation. 

It  is  as  much  the  function  of  the  national  government  to  protect  its  people 
from  disease  as  from  foreign  invasion  or  criminals.  "  It  is  bad  economy  to 
leave  this  work  mainly  to  the  weak  and  spasmodic  efforts  of  charity  or  to  the 
philanthropy  of  the  physicians." 

The  national  government  should  exercise  at  least  three  public  health  functions: 
First,  investigation;  second,  dissemination  of  information;  third,  administration. 
It  should  remove  the  reproach  that  more  pains  are  taken  to  protect  the  health  of  our 
cattle  than  of  human  beings.  It  should  provide  more  and  greater  laboratories  for 
research  in  preventive  medicine  and  public  hygiene.  Provision  should  also  be  made 
for  better  and  more  universal  vital  statistics,  without  which  it  is  impossible  to  know 
the  exact  condition  in  epidemics  or,  in  general,  the  sanitary  or  insanitary  conditions  in 
any  part  of  the  country.  It  should  aim,  as  should  state  and  municipal  legislation, 
to  procure  adequate  registration  of  births,  statistics  of  which  are  at  present  lacking 
throughout  the  United  States. 

The  national  government  should  prevent  transportation  of  disease  from  state 
to  state  in  the  same  way  as  it  now  provides  for  quarantine  and  the  protection  of  the 
nation  from  importation  of  disease  by  foreign  emigrants. 

It  should  provide  for  the  dissemination  of  information  in  regard  to  the  prevention 
of  tuberculosis  and  other  diseases,  the  dangers  of  impure  air,  impure  foods,  impure 
milk,  imperfect  sanitation,  ventilation,  etc.,  just  as  now  the  Department  of  Agriculture 
supplies  specific  information  to  the  farmer  in  respect  to  raising  crops  or  live  stock, 
so  should  one  of  the  departments  devoted  principally  to  health  and  education  be  able 
to  provide  every  health  officer,  school  teacher,  employer,  physician,  and  private  family 
with  specific  information  in  regard  to  public,  domestic,  and  personal  hygiene. 


220  HYGIENE 

People  in  this  country  are  going  to  have  such  a  department  of  health.  It  is 
closest  to  the  happiness  and  prosperity  of  the  people,  and  when  the  public  is  once 
educated  to  the  capabilities  of  modern  sanitation  and  that  the  warfare  against  disease, 
like  the  warfare  against  a  human  foe,  can  best  be  conducted  by  the  general  government' 
they  will  wonder  that  this  country  has  so  long  deferred  this  important  department. 

Bibliography,  Medical  Sociology,  Warbasse.   Military  Surgeon,  November, 
1908,  Rucker.    Report  on  National  Vitality,  July,  1909. 


Chapter  XI 

LOCAL  BOARDS  OF  HEALTH,  COUNTY,  AND  SANITARY 

OFFICERS 

Introductory  remarks  —  The  maze  of  laws  and  regulations  with  reference  to 
them  —  Their  duties  —  The  necessity  of  informing  oneself  regarding  local  regula- 
tions—  The  relationship  that  should  exist  between  these  officials  and  the  physician  — 
The  mistake  of  shifting  all  local  sanitation  away  from  local  to  state  authorities  —  City 
bacteriologists  and  chemists  and  their  usefulness  to  the  physician  and  public  —  The 
separate  problems  of  cities, 

/NTRODUCTORT  REMARKS.  It  has  been  claimed  that  in  general 
society  the  "  upper  crust  "  and  the  "  lower  crust  "  are  those  most  subject 

to  criticism.  Certainly  in  sanitation  the  upper  crust  of  federal  aid  is 
nearly  absent,  since  there  is  no  United  States  department  of  health,  as  is  ad- 
vocated in  the  chapter  immediately  preceding  this  one,  and  the  lower  crust 
has  to  do  with  the  subject  of  our  present  study.  Between  these  two  but 
imperfectly  worked  out  factors  in  sanitation  stand  the  splendidly  organized 
state  boards  of  health.  It  is  strange  that  above  and  below  the  state  organiza- 
tions in  the  nation  on  the  one  hand,  and  in  the  smaller  units  of  our  government 
on  the  other,  lie  the  weak  points  in  public  hygiene.  Our  republican  form  of 
government  is  partly  responsible  for  this  condition,  and  what  I  will  call  bene- 
volent centralization  will  alone  cure  this  ill  of  the  body  politico-sanitary. 

By  benevolent  centralization  is  meant  such  construction  of  the  Constitu- 
tion and  the  statutes  as  will  permit  such  desirable  reforms  as  uniform  divorce 
laws,  uniform  pure-food  laws,  uniform  registration  of  physicians,  uniform 
excise  laws,  uniform  regulations  as  regards  interstate  carriers  and  waterways, 
and  of  such  other  matters  as  are  of  interest  to  the  whole  people.  In  order  to 
bring  this  about,  it  is  necessary  for  the  federal  government  to  define  some 
standard,  as  it  has  in  the  matter  of  pure  food  and  drugs,  and  then  for  the 
sovereign  states  to  legislate  according  to  the  scheme  outlined. 

As  regards  local  boards  of  health  and  the  medical  and  other  sanitary 
officers  appointed  by  them,  it  may  be  said  that  it  requires  a  certain  degree  of 
training  to  produce  an  efficient  sanitary  officer  of  any  grade,  and  an  efficient 
administration  of  affairs  to  render  his  work  effective  to  the  betterment  of 
conditions. 

It  is  quite  natural  that  the  older  cities  and  states  should  have  established 
sanitary  regulations  under  bureaus  still  doing  effective  work,  and  it  is  to  be 
expected  that  the  authorities  will  be  very  slow  in  changing  satisfactory  con- 
ditions. Before  the  states  organized  boards  or  departments  of  health,  many 
of  the  cities  had  efficient  organizations  duly  operating  under  state  or  city 
charters.  It  would  probably  be  unwise  for  the  state  to  interfere  too  much 
with  the  work  of  such  local  boards.  And  yet,  notwithstanding  the  fact  that 
the  city  of  New  Orleans  and  the  state  of  Louisiana  maintained  for  many  years 
a  well-equipped  Mississippi  River  quarantine  station,  an  unbroken  line  of 
United  States  Supreme  Court  decisions  affirming  the  right  of  a  state  to  main- 


222  HYGIENE 

tain  quarantine  as  a  part  of  the  police  powers  guaranteed  the  separate  states 
by  the  federal  Constitution  and  incidentally  to  collect  quarantine  inspection 
fees;  that  the  statutes  of  the  state  give  the  state  board  exclusive  control  of 
maritime  quarantine,  and  several  other  legal  factors  unnecessar)'  for  our  argu- 
ment, yet  the  Mallory-Williams  bill  passed  by  Congress  resulted  in  the  state 
selling  to  the  United  States  Public  Health  and  Marine  Hospital  Service  the 
existing  plants  and  abdicating  to  the  service  a  large  part  of  the  work  and  privi- 
leges previously  done  so  well  by  the  state.  The  sale  was  in  the  line  of  progress 
and  uniformity  in  the  matter  of  gulf-states  maritime  quarantine.  If  Loui- 
siana submitted  to  this  matter  and  yielded  her  manifest  legal  rights,  other 
states  can  as  well  afford  to  emulate  her  example.  Furthermore,  counties  and 
municipalities  can  afford  to  yield  local  regulations  for  the  benefits  of  uniform- 
ity with  other  counties  and  municipalities.  The  end  result  of  this  sort  of 
thing  will  be  beneficial  and  tend  toward  the  improvement  of  the  service. 

Were  I  to  give  here  the  regulations  of  all  of  the  states  bearing  upon  local 
health  officials,  this  chapter  would  be  extended  beyond  all  limits;  but  it  may 
be  profitable  to  select  a  few  widely  separated  states  and  partially  define  their 
regulations.  This  will  help  us  to  reach  some  just  conclusion  as  to  the  proper 
method  of  organization  and  of  administration  of  local  boards  of  health. 

The  statutes  of  Connecticut  provide  that:  "  The  judges  of  the  superior  court 
shall  appoint  for  each  county  a  health  officer.  The  person  so  appointed  shall  be  an 
attorney  at  law,  residing  in  the  county  for  which  he  shall  be  appointed."  The  statute 
outlines  his  duties  and  confers  upon  him  the  proper  powers  inclusive  of  those  of  a 
grand  juror  and  a  prosecuting  officer.  This  county  officer  appoints  town  health 
officers  who  must  be  learned  in  medicine  and  sanitary  science.  The  regulations 
adopted  by  the  towns  must  be  approved  by  the  state  board  of  health.  Cities  and 
boroughs  have  health  officers  appointed  by  the  mayors  and  wardens,  and  confirmed 
by  councils. 

Circular  110  of  the  New  Jersey  State  Board  of  Health,  says,  quoting  the 
law: 

(Approved  April  8,  1903  —  P.  L.  1903,  p.  453.) 

1.  To  the  end  that  local  boards  of  health  may  be  enabled  to  secure  the  services 
of  capable  health  officers  and  trained  sanitary  inspectors,  the  board  of  health  of  the 
state  of  New  Jersey  is  hereby  authorized  to  cause  examinations  to  be  made  by  such 
persons,  and  at  such  times  and  places  as  it  may  appoint,  and  under  such  rules  and 
regulations  as  it  may  adopt,  for  the  purpose  of  determining  the  qualifications  of  appli- 
cants for  license  as  health  officers  and  sanitary  inspectors;  every  such  examination 
shall  be  in  such  subjects  and  conducted  in  such  manner  as  the  board  of  health  of  the 
state  of  New  Jersey  shall  direct,  and  every  applicant  whose  examination  shall  be  ap- 
proved by  said  state  board  shall  receive  a  license  as  health  officer  or  sanitary  inspector 
as  hereinafter  provided. 

2.  Said  state  board  shall  issue  four  classes  of  licenses,  to  wit,  health  officers' 
licenses,  sanitary  inspectors'  licenses  of  the  first  class,  sanitary  inspectors'  licenses  of 
the  second  class,  and  sanitary  inspectors'  licenses  of  the  third  class;  every  person 
whose  examination  as  an  applicant  for  a  health  officers'  license  is  approved  shall  be 
entitled  to  receive  such  license,  and  every  person  whose  examination  as  an  applicant 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  223 

for  a  sanitary  inspectors'  license  of  the  first  class,  the  second  class,  or  the  third  class, 
is  approved  shall  be  entitled  to  receive  a  sanitary  inspectors'  license  of  the  first  class, 
the  second  class,  or  the  third  class,  according  to  the  approval  of  his  examination. 

3.  Any  person  licensed  as  a  health  officer  shall  be  eligible  to  appointment  as 
such  oflGcer  by  any  local  board  of  health  in  this  state,  and  when  so  appointed  shall, 
during  the  term  of  his  appointment,  and  subject  to  the  superior  authority  of  such  local 
board,  be  its  general  agent  for  the  enforcement  of  its  ordinances  and  the  sanitary  laws 
of  this  state  within  the  territorial  jurisdiction  of  such  local  board. 

4.  Any  person  licensed  as  a  sanitary  inspector  of  the  first  class  shall  be  eligible 
to  appointment  as  such  inspector  by  any  local  board  of  health  in  this  state;  any  person 
licensed  as  a  sanitary  inspector  of  the  second  class  shall  be  eligible  to  appointment  as 
such  inspector  by  any  local  board  of  health  in  any  municipality  in  this  state,  not  being 
a  city;  any  person  licensed  as  a  sanitary  inspector  of  the  third  class  shall  be  eligible  to 
appointment  as  such  inspector  by  any  local  board  of  health  in  any  township  of  this 
state;  the  title  "  sanitary  inspector,"  as  used  in  this  act,  shall  be  understood  to  apply 
to  every  officer  appointed  by  a  local  board  of  health  to  aid  in  the  enforcement  of  the 
sanitary  laws  of  this  state,  or  the  rules,  regulations,  and  ordinances  of  such  local  board, 
excepting  health  officers  and  persons  performing  merely  clerical  duties  in  the  office  of 
such  local  board;  any  sanitary  inspector  so  appointed  shall  be  the  agent  of  the  local 
board  appointing  him  for  the  performance  of  such  services  as  such  local  board,  or  any 
health  officer  under  the  authority  of  such  local  board  shall  assign  unto  him. 

5.  No  local  board  of  health  shall,  on  or  after  the  first  day  of  January,  nineteen 
hundred  and  five,  appoint  any  person  as  health  officer  who  is  not  the  holder  of  a  health 
officers'  license  granted  as  in  this  act  above  prescribed,  or  as  sanitary  inspector,  who 
is  not  the  holder  of  a  sanitary  inspectors'  license  of  the  class  hereinabove  prescribed 
for  the  municipality  or  township  within  which  the  appointing  local  board  shall  have 
jurisdiction;  provided,  however,  that  nothing  in  this  act  shall  prevent  any  local  board 
of  health  from  continuing  in  office  any  person  now  filling  the  office  of  health  officer  or 
sanitary  inspector  for  such  local  board. 

There  are  about  four  hundred  and  seventy  sanitary  districts  in  the  state 
and  many  of  them  have  not  conformed  to  the  law,  but  the  number  is  increasing 
as  capable  inspectors  are  found.  Local  boards  are  general  throughout  the 
state,  and  the  tendency,  under  the  guidance  of  the  active  state  board,  is  to 
place  local  sanitation  in  skilled  hands. 

The  District  of  Columbia  has  abolished  the  board  of  health,  and  in  Sec- 
tion 9  of  the  laws  and  regulations  provides  that  the  commissioners  of  the 
district  may  employ  a  health  officer  and  skilled  inspectors.  And,  as  more 
fully  described  in  Chapter  IX,  the  system  works  out  excellently.  From  my 
limited  observation  in  Washington,  I  am  impressed  with  the  manifest  advan- 
tages of  employing  local  officials  who  are  skilled  in  the  legal,  medical,  chemi- 
cal, and  engineering  features  of  sanitation. 

In  Kentucky  it  is  the  duty  of  the  state  board  of  health  to  appoint  three 
physicians  in  each  county,  who,  together  with  the  county  judge  and  one  per- 
son elected  by  the  fiscal  court  of  each  county,  shall  constitute  a  local  or  county 
board  of  health.  They  have  power  to  appoint  health  officers  and  do  all  the 
acts  devolving  upon  such  officers.  Cities  and  boroughs  delegate  the  appoint- 
ments to  councils. 

The  Indiana  State  Board  of  Health  is  illustrative  of  a  class  of  energetic 
boards  not  very  sharply  limited  by  legislation  as  to  details.     The  attorney 


224  HYGIENE 

general  of  the  state  says:  "  The  rules  established  by  the  state  board  of  health 
have  the  force  of  statutes,  and  a  law  authorizing  their  adoption  is  constitu- 
tional." Under  such  powers  the  county  boards  are  regulated  very  distinctly 
by  the  executive  officers  of  the  state  board,  and  the  county  health  officer  is 
really  an  employee  of  the  state  board.  The  city,  borough,  and  township 
officers  are  responsible  to  the  state  board,  and  the  numerous  deputies  appointed 
are  used  to  help  the  work  of  an  elaborate  and  complicated  mechanism  of 
a  rather  militant  but  certainly  effective  character. 

Before  discussing  this  matter,  permit  me  to  refer  to  the  state  board  of 
health  of  Wisconsin.  This  board  has  issued  a  pamphlet  upon  "  The  Powers 
and  Duties  of  Local  Boards  of  Health."     From  it  I  clip  the  following: 

FUNCTIONS  OF  THE  STATE  BOARD  OF  HEALTH 

It  is  frequently  understood  that  the  state  board  of  health  has  greater  powers  than 
the  law  provides.  In  a  decision  of  the  supreme  court  of  this  state,  wherein  the  power 
to  make  rules  relating  to  vaccination  was  considered  invalid,  the  court  said:  "The 
state  board  of  health  is  a  creation  of  the  statute,  and  has  only  such  powers  as  the  statute 
confers.  It  has  no  common  law  powers.  ....  The  powers  of  the  state  board  of 
health,  though  quite  general  in  terms,  must  be  held  to  be  limited  to  the  enforcement  of 
some,  statute  relating  to  some  particular  condition  or  emergency  in  respect  to  public 
health;  and,  although  they  are  to  be  fairly  and  liberally  construed,  yet  the  statute 
does  not,  either  expressly  or  by  fair  implication,  authorize  the  board  to  enact  a  rule  or 
regulation  which  would  have  the  force  of  a  law  changing  the  statute  in  relation  to  the 
admission  and  the  right  of  pupils  of  a  proper  school  age  to  attend  the  public  schools. 
The  state  board  of  health  has  no  legislative  power  properly  so  called,  and  none  could  be 

delegated  to  it.     It  is  purely  an  administrative  body It  cannot  be  doubted  but 

that  under  proper  general  provisions  of  law  in  relation  to  the  prevention  and  suppres- 
sion of  dangerous  contagious  diseases,  authority  may  be  conferred  by  the  legislature 
upon  the  state  board  of  health,  or  local  boards,  to  make  reasonable  rules  and  regula- 
tions for  the  carrying  into  effect  such  general  provisions  which  will  be  valid  and  may 
be  enforced  accordingly.  The  making  of  such  rules  and  regulations  is  an  admin- 
istrative function,  and  not  a  legislative  power As  to  the  matter  of  inspections 

authorized  by  Section  1409b  (S.  &  B.  A.  S.)  to  ascertain  the  presence  of  the  intro- 
duction of  Asiatic  cholera,  or  other  dangerous  and  contagious  diseases,  and  the  power 
conferred  upon  the  inspector  to  enter  any  building,  vessel,  railway  car,  etc.,  as  well  as 
the  quarantine  authorized  by  Section  1409b  (S.  &  B.  A.  S.),  the  power  of  the  state 
board  of  health  to  make  proper  rules  and  regulations  to  effectuate  the  general  purposes 
thus  declared  would  seem  to  be  free  from  doubt." 

It  would  appear  by  this  decision  that  the  state  board  of  health  can  make  rules  and 
regulations  pertaining  to  the  carrying  into  effect  of  any  law  passed  by  the  legislature. 
It  also  has  general  powers  pertaining  to  quarantine  in  the  state,  but  other  than  this  its 
principal  functions  are  advisoiy  to  local  boards  of  health  and  local  authorities.  It  is 
the  function  of  the  state  board  of  health  to  see  that  all  local  boards  of  health  are  duly 
and  legally  organized,  and  that  the  health  officers  of  those  boards  make  proper  reports 
and  returns  to  the  state  board  of  health.  It  is  also  incumbent  upon  the  state  board  to 
investigate  any  outbreaks  of  contagious  diseases  in  the  state;  and,  when  requested,  or 
when  it  is  deemed  advisable,  to  investigate  the  sanitary  conditions  of  pubHc  buildings, 
sewerage  disposal,  water  supplies,  and  to  advise  local  authorities  relative  to  the  sanitary 
construction  and  management  of  the  same;  also  to  study  the  vital  statistics  of  the  state 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  225 

as  far  as  possible,  and  to  publish  and  issue  such  information  to  the  public  as  in  the 
judgment  of  the  board  seems  proper  and  necessary  for  the  best  interests  and  welfare 
of  the  public  health. 

Here  are  two  very  different  types  of  board,  and  it  is  a  question  in  my  mind 
as  to  which  is  the  better  system.  I  have  observed  the  working  out  of  both 
forms  of  administration.  The  Indiana  plan  works  smoothly  after  a  time,  but 
not  at  first.  Centralizing  power  is  certain  to  offend  some  of  the  local  men 
whose  wings  are  clipped.  There  is  also  a  tendency  (in  some  states)  to  take 
the  matter  into  politics  and  to  load  up  the  state  with  a  lot  of  worse  than  worth- 
less appointments  and  to  employ  an  army  of  unnecessary  clerks  urged  by 
the  political  coterie.  Also  friction  and  jealousies  arise  and  foolish  things 
are  done  by  parties  feeling  aggrieved  and  by  young  and  inexperienced  officers 
who  feel  their  prerogative  and  are  readily  ruffled  by  trifles. 

After  a  time,  provided  the  executive  officer  is  tactful  and  is  politically 
clean,  the  incompetent  men  are  weeded  out  of  the  service,  the  field  personelle 
"  team  work  "  improves,  the  profession  comes  to  recognize  the  valuable 
service  being  rendered,  the  fossilized  old  "  boards  "  give  way  to  real  sanita- 
rians, and  the  general  public  apprehends  what  the  state  board  is  trying  to  do. 
It  is  doubtless  true  that  the  ultimate  form  of  sanitary  administration  will  be 
largely  along  these  lines,  but  with  the  state  boards  secondary  to  the  federal 
one  and  the  local  boards  uniform  and  vastly  more  effective  than  they  are  at 
present. 

On  the  other  hand,  the  Wisconsin  plan  has  an  element  of  safety,  even 
though  it  may  be  less  efficient.  What  is  called  "  government  by  commission  " 
is  rapidly  becoming  a  nuisance.  We  have  about  thirty-five  commissions  in 
Pennsylvania  all  helping  our  legislature  and  courts  to  be  lazy,  and  all  costing 
the  state  a  lot  of  money.  It  is  not  always  safe  to  limit  the  judiciary  and  the 
legislative  bodies  by  delegating  their  powers  to  commissions  or  even  to  health 
authorities.  It  may  work  excellently  with  the  health  authorities  so  long  as 
good  and  upright  men  hold  the  power,  but  we  have  no  guarantee  that  the  other 
type  may  never  hold  the  office. 

Legislatures  may  readily  empower  state  boards  to  do  all  that  is  done  in 
Indiana,  and  the  orders  of  the  board  are  legal  and  its  powers  very  great,  but 
only  the  future  will  determine  whether  or  no  it  is  wise  for  a  legislature  to  do  so, 
or  if  it  would  be  better  for  the  board  to  be  subject  to  regular  supervision  by  the 
courts  and  to  possess  no  inherent  common  law  powers.  No  one  individual 
can  pass  adequate  judgment  upon  this  matter,  but  it  impresses  me  that  the 
issue  will  result  in  a  form  of  compromise  method.  Meanwhile,  it  is  incum- 
bent upon  the  profession  and  the  public  to  obey  the  laws  as  they  are. 

As  the  issue  influences  local  boards,  there  is  a  great  tendency  in  human 
nature  to  value  individual  privilege,  and  local  boards  may  feel  aggrieved 
when  some  one  is  set  over  them.  But  the  fact  that  they  value  their  privileges 
is  no  guarantee  at  all  that  they  will  attend  to  their  work.  Most  local  boards 
need  a  boss.  The  whole  question  must  be  looked  at  from  the  standpoint  of 
public  policy,  and  if  somewhat  rigid  methods  get  trained  sanitary  service  for 
the  public,  the  profession  must  put  up  with  inconveniences.  In  the  long  run, 
capable  local  boards  will  be  given  all  authority  they  need. 


226  HYGIENE 

Wisconsin  provides  for  local  organization  as  follows : 

ORGANIZATION  OF  LOCAL  BOARDS  OF  HEALTH 

Chapter  57,  laws  of  1898,  hoards  of  health,  their  officers,  powers^  and  duties.  Sec- 
tion 1411:  The  town  board,  village  board,  and  common  council  of  every  town,  village, 
and  city  shall,  within  thirty  days  after  each  annual  election,  organize  as  a  board  of 
health,  or  appoint  wholly  or  partially  from  its  own  members,  a  suitable  number  of 
competent  persons  who  shall  organize  as  a  board  of  health  for  such  town,  village,  or 
city.  The  officers  of  such  board  shall  include  a  chairman,  a  clerk,  and  a  health  officer, 
who  shall  be  ex-officio  a  member  of  such  board  and  its  executive  officer;  all  such  officers 
shall  be  elected  by  the  board  immediately  after  its  organization.  Every  board  of  health 
as  thus  constituted  shall  exercise  all  the  powers  and  perform  all  the  duties  prescribed 
in  this  chapter  within  the  limits  of  the  town,  village,  or  city  of  which  they  are  such 
officers.  Every  health  officer  so  appointed  shall  be,  whenever  practicable,  a  reputable 
physician;  he  shall  hold  office  during  the  pleasure  of  such  board  and  until  the  qualifi- 
cation of  his  successor;  if  a  vacancy  occurs  in  his  office  the  board  of  health  shall  imme- 
diately fill  the  same  by  an  election.  The  foregoing  provisions  shall  not  apply  to  any 
city  or  village  in  which  a  board  of  health  and  a  health  officer  are  provided  for  by  the 
charter  thereof;  but  every  such  board,  whether  organized  under  the  provisions  of 
this  section  or  otherwise,  shall,  immediately  after  each  annual  or  other  organization, 
report  to  the  secretary  of  the  state  board  of  health  the  names,  post-office  addresses, 
and  o^ccupations  of  the  officers  thereof,  and  make  such  report  whenever  a  new  health 
officer  is  chosen.  Every  board  of  health  may  take  such  measures  and  make  such  rules 
and  regulations  as  they  may  deem  most  effectual  for  the  preservation  of  the  public 
health.  They  may  appoint  as  many  persons  to  aid  them  in  the  execution  of  their 
powers  and  duties  as  they  think  proper,  regulate  the  fees  and  charges  of  every  person 
so  employed  by  them,  and  fix  the  salary  of  the  health  officer,  examine  into  all  nuisances, 
source  of  filth,  and  causesof  sicknesses,  and  make  such  rules  and  regulations  respecting 
the  same  as  they  may  judge  necessary  for  the  public  health  and  safety  of  the  inhabitants. 

Note. —  Board's  Powers.  A  statute  which  gives  a  board  of  health  "  all  the 
powers  necessary  and  proper  for  the  preservation  of  the  public  health  and  the  preven- 
tion of  the  spreading  of  malignant  diseases,"  and  makes  it  the  duty  of  such  board  "  to 
examine  into  all  nuisances,  sources  of  filth  injurious  to  the  public  health,  and  cause  to 
be  removed  all  filth  found  within  the  town  which  in  their  judgment  shall  endanger  the 
health  of  the  inhabitants,"  gives  express  power  to  decide  what  is  filth;  and  if  a  board 
merely  errs  in  judgment  there  can  be  no  redress  given  a  party  who  complains  of  its 
acts. 

Raymond  vs.  Fish,  51  Conn.,  80. 

The  board's  determination  of  questions  of  discretion  and  judgment  in  the  dis- 
charge of  its  duties  is  in  the  nature  of  a  judicial  decision  and  within  the  scope  of  the 
powers  conferred,  and  for  the  purposes  for  which  the  determination  is  required  to  be 
made,  it  is  conclusive.  It  is  not  to  be  impeached  or  set  aside  for  error  or  mistake  of 
judgment,  nor  to  be  reviewed  in  the  light  of  new  or  additional  facts.  The  officers  or 
board  to  whom  such  determination  is  confided,  and  all  those  employed  to  carry  it 
into  effect  or  who  may  have  occasion  to  act  upon  it,  are  protected  by  it  and  may  safely 
rely  upon  its  validity  for  their  defense. 

Salem  vs.  Eastern  Ry.  Co.,  98  Mass.,  431. 

In  the  regulations  following,  any  possible  deficiencies  in  the  powers  of  the 
state  board  are  largely  imposed  upon  the  local  ones. 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  227 

The  Illinois  State  Board  of  Health  issues  a  pamphlet,  "  Public  Health 
Laws  of  Illinois  and  Sanitary  Memoranda,"  that  contains  such  admirable 
drafts  of  model  local  board  of  health  laws,  that  persons  in  doubt  as  to  what 
should  be  required  should  read  this  publication.  The  Illinois  county  and 
township  boards  are  organized  as  follows: 

Section  116.  How  created  —  powers  and  duties. —  The  board  of  county  com- 
missioners in  counties  not  under  township  organization,  and  the  supervisor,  assessor, 
and  town  clerk  of  every  town  in  counties  under  township  organization,  shall  constitute 
a  board  of  health,  and,  on  the  breaking  out  of  any  dangerously  communicable  diseases 
in  their  county  or  town,  or  in  the  immediate  vicinity  thereof,  it  shall  be  their  duty  to 
make  and  enforce  such  rules  and  regulations  tending  to  check  the  spread  of  the  disease 
within  the  limits  of  such  county  or  town  as  may  be  necessary;  and  for  this  purpose  they 
shall  have  power  to  quarantine  any  house  or  houses  or  place  where  any  infected  person 
may  be,  and  cause  notices  of  warning  to  be  put  thereon,  and  to  require  the  disinfec- 
tion of  the  house  or  place:  Provided,  that  nothing  in  this  Act  shall  apply  to  any  terri- 
tory lying  within  the  corporate  limits  of  any  incorporated  city  or  village:  Provided, 
further,  that  in  case  the  board  of  health  in  any  county  not  under  township  organization, or 
of  any  township  in  counties  under  township  organization  shall  fail,  refuse,  or  neglect  to 
promptly  take  the  necessary  measures  to  preserve  the  public  health,  or  in  case  any  such 
board  of  health  shall  refuse  or  neglect  to  carry  out  the  rules  and  regulations  of  the  state 
board  of  health,  that  thereupon  the  state  board  of  health  may  discharge  such  duties  and 
collect  from  the  county  or  township,  as  the  case  may  he,  the  reasonable  costs,  charges, 
and  expenses  incurred  thereby. 

The  Iowa  State  Board  of  Health  makes  no  elaborate  provision  for  local 
boards,  mayors,  and  councils  of  towns  and  cities  and  clerks  of  townships 
attending  to  the  duties  and  employing  such  physicians  as  they  see  fit.  They 
must  appoint  a  health  officer  and  certain  regulations  of  the  state  board  must 
be  adopted  verbatim. 

Kansas  makes  the  following  provision  for  local  boards : 

6662.  Local  boards.  Section  7.  The  county  commissioners  of  the  several 
counties  of  this  state  shall  act  as  local  boards  of  health  for  their  respective  counties. 
Each  local  board  thus  created  shall  elect  a  physician,  preference  being  given  to  adepts 
in  sanitary  science,  who  shall  be  ex  officio  a  member  of  said  local  board  and  the  health 
officer  of  the  same.  He  shall  hold  his  office  during  the  pleasure  of  the  board,  but  may 
be  removed  for  just  cause  at  any  regular  meeting  of  the  same  by  a  majority  of  the  mem- 
bers voting  therefor,  on  which  motion  he  shall  not  vote.  The  local  boards  of  health 
hereby  created  shall  not  supersede  or  in  any  way  interfere  with  such  boards  established 
by  municipal  regulations  in  any  of  the  counties  of  this  state;  but  all  local  boards  of 
health  of  this  state,  created  by  this  act,  or  existing  by  authority  of  municipal  law,  shall 
be  governed  by  the  provisions  of  this  act. 

The  territorial  board  of  health  of  Arizona  make  very  complete  provision 
for  local  boards,  the  gist  of  the  regulations  being  as  follows: 

COUNTY  BOARDS  OF  HEALTH 

Section  6.  There  are  hereby  established  county  boards  of  health,  composed  of  a 
president,  a  vice-president,  and  a  superintendent.  The  chairman  of  the  board  of 
supervisors  in  each  county  shall  be  ex  officio  president  of  the  county  board  and  the 


228  HYGIENE 

district  attorney  of  such  county  shall  be  ex  officio  vice-president  of  such  board.  The 
board  of  supervisors  shall  appoint  a  superintendent  of  public  health  for  the  county, 
who  shall  be  a  practicing  physician  within  the  county. 

Section  9.  The  several  county  boards  of  health  shall  have  power  within  their 
respective  counties,  outside  of  the  corporate  limits  of  cities  having  a  city  board  of 
health,  subject  to  the  supervisory  control  of  the  territorial  board  of  health  and  the 
superintendent  of  public  health,  to  do  and  perform  all  the  things  mentioned  in  sub- 
divisions 3,  4,  5,  6,  7,  and  8  of  Section  4.  All  expenses  actually  and  necessarily  in- 
curred by  the  county  board  of  health  in  carrying  out  the  provisions  of  this  article  shall 
be  audited  by  the  board  and  certified  to  the  county  supervisors,  and  shall  be  paid  the 
same  as  other  county  expenses  are  paid. 

Section  10.  The  county  superintendent  of  health  shall  have  charge  of  and  super- 
intend, subject  to  the  approval  of  the  board  of  which  he  is  a  member,  and  the  super- 
visory control  of  the  territorial  board  of  health  and  the  superintendent  of  public  health. 

A  survey  of  the  field,  viewed  historically,  shows  that  the  gulf  coast 
and  the  large  cities  have  found  it  most  incumbent  upon  them  to  provide  for 
local  health  boards.  In  these  sections  the  boards  have  been  gradually 
brought  up  to  a  point  of  efficiency.  One  of  the  most  elaborate  organizations 
is  in  New  Orleans.  Ports  and  port  cities  have  been  compelled  to  organize 
an  effective  force.  Until  recently  the  interior  Southern  states  have  been 
remiss'',  but  they  are  now  organizing  along  quite  modem  lines,  although  much 
territory  is  not  fully  complying  with  the  new  and  somewhat  untried  state 
laws.  In  the  old  eastern  section  of  the  country-  there  are  a  host  of  alleged 
local  boards  of  health  not  at  all  in  sympathy  with  the  new  order  of  things  being 
adopted  by  most  of  the  Eastern  and  Middle  states.  The  state  boards  are  handi- 
capped by  a  lot  of  old  charters  giving  these  local  boards  a  legal  standing. 
Some  of  them  are  reorganizing,  as  requested  by  the  state  boards,  but  some 
parsimonious  counties  are  very  remiss,  and  it  is  difficult  for  the  state  boards 
to  get  them  in  line.  The  large  eastern  and  central  cities  have  efficient  organi- 
zations. In  theAVest,  commendable  advance  is  being  made.  There  are  few 
old  charters  and  the  country  is  newer,  and  hence  it  is  comparatively  easy  to 
organize  effectively.     In  many  states  these  matters  have  been  well  adjusted. 

As  to  the  form  of  law  advisable  it  would  not  be  fair  for  me  to  discriminate. 
My  opinion  would  be  of  little  value.  Conditions  vary  and  communities  have 
different  problems  and  differing  kinds  of  people  with  which  to  deal.  Only  a 
few  things  do  I  care  to  outline.  The  first  one  is  that  politics  is  the  bane  of 
local  health  boards.  It  impresses  me  that  when  the  appointment  of  the 
members  of  these  boards  is  vested  with  the  courts,  politics  can  be  largely 
avoided.  Allow  me  also  to  commend  the  feature  of  the  Kentucky  law  giving 
the  medical  societies  a  voice  in  the  matter. 

New  Jersey  has  a  splendid  provision  in  requiring  inspectors  to  be  trained 
and  to  pass  an  examination  for  license.  One  of  the  urgent  needs  is  for  trained 
men.  Better  fewer  laws  and  better  men.  A  trained  man  will  give  good 
service  under  poor  laws,  but  an  ignorant  official  must  have  ever}^thing  in 
print  to  get  him  to  do  one  half  of  the  necessan'  work. 

It  must  not  be  forgotten  that  the  state  health  departments  may  be  called 
upon  to  meet  frightful  emergencies.     Therefore  it  is  well  to  confer  large  pow- 


^.■ 


MUNICIPAL    CREMATORIUM,    DISTRICT    OF    COLUMBIA 

Here  are  burned  all  dead  bodies  of  paupers 

SMALLPOX    HOSPITAL,    DISTRICT    OF    COLUMBIA 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  229 

ers  upon  them.  They  must  be  able  to  declare  a  sort  of  martial  law,  as  it  were, 
but  martial  law  is  not  declared  for  a  mere  street  fight.  Neither  should  the 
extreme  powers  of  the  state  health  boards  be  used  in  the  ordinary  course  of 
affairs.  A  policeman  may  deal  with  the  first  and  a  health  officer  with  the 
other.  It  is  poor  policy  to  call  out  the  militia  when  the  sheriff  can  control  the 
situation,  and  it  is  equally  poor  policy  to  call  out  the  state  board  when  the 
affair  is  of  purely  local  import.  Any  county  would  be  remiss  if  it  did  not  have 
a  sheriff  and  district  attorney,  and  it  is  equally  remiss  if  it  does  not  have  a 
local  health  board  capable  of  handling  ordinary  matters  of  local  sanitation. 
As  there  are  grades  of  courts  and  attorneys  general  as  well  as  district  attor- 
neys, so  there  are  grades  of  health  officers,  and  each  should  constitute  a  part 
of  one  chain  and  act  as  co-ordinate  parts  of  one  harmonious  whole. 

In  general  we  practitioners  of  medicine  can  well  leave  to  the  trained  sani- 
tarian the  details  of  organization  of  local  boards.  The  whole  matter  is  a 
specialty,  being  very  carefully  studied  out  by  as  able  and  honest  a  class  of 
men  as  we  have  in  the  land,  and  it  is  not  at  all  likely  that  they  will  perpetuate 
any  mistakes  definitely  shown  to  exist  in  the  present  system. 

Duties  of  local  boards. —  Upon  the  appointment  of  a  local  board,  it  is 
incumbent  upon  them  to  organize  as  provided  by  law.  Whatever  views  one 
may  hold  upon  abstract  questions  of  law,  it  is  the  duty  of  every  officer  under 
the  law  to  yield  implicit  obedience  to  the  statutes  governing  his  appointment 
and  the  conduct  of  his  office,  and  to  govern  his  individual  conduct  by  such 
orders  as  may  emanate  from  the  constituted  authorities  superior  to  him. 
Members  of  boards  of  health,  either  lay  or  professional,  should  realize  that 
their  appointment  is  no  joke  or  merely  for  the  community  to  "put  on  a  front." 
The  health  laws  are  meant  to  be  enforced  just  as  much  as  are  other  laws. 
Supposedly  dead  laws  are  like  supposedly  dead  wires, they  may  get  crossed  in 
time  of  storm  and  woe  betide  the  luckless  individual  who  picks  them  up. 
Dead  wires  should  be  connected  up  or  taken  down;  so  with  dead  laws. 

The  academic  attitude  has  no  place  in  sanitation.  One  may  scoff  at 
therapeutics  and  medical  theories  to  his  heart's  content,  if  he  is  so  minded, 
but  disease,  sin,  and  dirt  won't  rub  out  and  must  be  reckoned  with  as  positive 
entities.  A  mere  altruist  or  academic  theorist  is  a  nuisance  upon  a  health 
board,  to  be  dealt  with  by  them  as  are  other  nuisances.  The  first  duty  of  a 
member  of  a  board  is  to  fully  inform  himself  upon  the  law;  not  what  he 
thinks  the  laws  should  be  but  what  they  are.  Then  he  should  realize  that  it 
is  "  up  to  him  "  to  enforce  the  laws. 

But  the  interpretation  of  the  law  may  present  difficulties  in  certain  specific 
instances.  Let  no  layman  arrogate  to  himself  judicial  decision  or  ruling. 
That  is  for  the  courts  and  the  constituted  officers  of  the  courts  or  those  speci- 
fically charged  with  the  execution  of  the  law.  I  say  specifically  charged.  In 
regard  to  the  health  laws,  states  differ  in  this  regard,  and  all  local  boards 
should  be  sure  of  their  ground.  Every  local  board  should  have  competent 
legal  advice. 

Local  boards  must  have  some  definite  attitude  toward  physicians.  There 
are  two  relations  to  be  maintained;  first,  that  toward  the  physicians  who  are 
entrusted  with  the  medical  part  of  the  work  of  public  sanitation;    second, 


230  HYGIENE 

that  toward  the  private  practitioner  of  medicine.  The  attitude  toward  the 
first  class  should  be  the  same  as  that  assumed  with  the  lawyer  or  the  chemist 
employed  in  public  health  work.  Each  man  is  assumed  to  be  an  expert  in 
his  special  line  of  endeavor.  If  he  is  not  willing  to  became  expert,  release 
him  from  an  irksome  task  and  get  a  man  who  takes  a  real  interest  in  his  work. 
There  are  lazy  lawyers  and  lazy  doctors  and  they  have  no  place  in  public 
health  work.  Local  boards  have  some  difficulty  in  securing  physicians  who 
understand  the  practical  side  of  the  work.  The  mere  fact  that  a  man  holds  a 
medical  diploma  does  not  signify  that  he  is  a  sanitary  expert  any  more  than  it 
indicates  that  he  is  an  experienced  surgeon.  But  any  properly  educated  and 
earnest  physician  can  become  a  good  sanitarian,  provided  he  has  some  know- 
ledge of  modern  laboratory  methods  and  a  fair  understanding  of  chemistry. 
Physicians  who  do  not  possess  such  knowledge  should  not  be  appointed  upon 
health  boards.  The  political  doctor  may  or  may  not  become  a  good  health 
officer,  but  the  ratio  is  about  16  to  1  and  generally  "  politics  doth  make 
cowards  of  us  all."  If  politics  must  be  a  factor,  it  should  not  be  mixed  in  with 
the  medical  end  of  affairs.  Unless  a  physician  possesses  a  fair  share  of  spunk 
and  executive  ability,  he  makes  a  poor  health  officer,  and  if  he  goes  into  the 
work  for  the  money  he  can  get  out  of  it  and  for  nothing  else,  the  sooner  he 
is  dropped  the  better  for  the  service.  On  the  other  hand,  a  medical  man  who 
is  woTth  having  is  worth  paying  all  that  his  skilled  services  are  worth  to  the 
community.  Only  a  well-paid  line  of  work  will  secure  and  hold  good  men, 
and  the  state  has  no  more  right  to  free  medical  than  to  free  legal  services. 

As  to  practicing  physicians,  there  is  a  lot  of  temper  wasted  by  them  and 
by  health  officers  in  contact  with  them,  that  may  just  as  well  be  saved.  Both 
sides  are  often  in  the  wrong.  It  must  not  be  forgotten  that  "  great  bodies 
move  slowly,"  and  that  the  medical  profession  has  long  enjoyed  certain 
immunities  and  has  its  conventions  and  precedents.  It  is  not  to  be  ex- 
pected that  men  graduating  many  years  ago  will  immediately  apprehend  the 
point  of  view  of  younger  men  fresh  from  the  schools.  Many  capable  phy- 
sicians are  not  informed  concerning  the  sanitary  advances  and  necessities  of 
the  day,  and  cannot  see  the  need  for  many  of  the  regulations  imposed  upon 
them.  If  the  state  undertook  to  regulate  the  legal  ills  of  the  citizens  2nd 
expected  the  lawyers  to  report  to  some  board  all  cases  of  infectious  conten- 
tion and  epidemic  litigation  in  order  that  the  board  should  pour  the  oil  of 
peace  over  the  wounds  and  cut  the  law}  er  out  of  the  job,  these  gentlemen 
would  mob  the  legislature.  And  yet  it  would  be  a  pretty  good  thing  for  the 
state  to  do  and  would  save  an  immense  sum  to  the  citizens  and  to  the  state. 
Possibly  it  may  be  undertaken  some  day  and  will  result  in  a  host  of  lawyers 
having  very  little  to  do  and  yet  assist  (free  of  cost)  in  destroying  their  own 
business.  That  is  exactly  what  the  state  is  asking  the  doctors  to  do  and  the 
state  is  right.     "  What  is  sauce  for  the  goose  is  sauce  for  the  gander." 

Human  nature  is  the  same  in  both  professions, and  in  both  of  these  lines 
of  work  there  is  plenty  of  necessary  work  to  do  for  a  limited  number  of  able 
men.  There  are  many  good  lawyers  who  believe  that  their  chief  function  is 
to  prevent  litigation,  just  as  there  are  many  good  doctors  who  think  that  their 
chief  function  is   to    prevent  disease.      Ultimately  an  enlightened  public 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  231 

conscience  will  demand  that  both  lawyers  and  doctors  who  do  not  feel  that 
way  should  not  be  allowed  to  practice,  and  the  public  will  be  right. 

But  "  ultimately  "  may  be  a  long  time  coming,  and  the  fact  remains  that 
all  professions  are  full  ("  in  this  present  evil  age  ")  of  men  who  have  none 
but  a  business  conscience  and  cannot  rise  above  sordid  impulses.  We  all 
cry  "  grafter!  "  but  take  good  care  of  our  own  little  graft  that  we  dignify 
with  some  better  name.  We  cannot  blame  some  men  because  they  cannot 
see  beyond  their  own  noses.  A  few  centuries  ago  some  well-meaning  and 
righteous  men  devised  systems  of  theology  rejected  in  this  more  humanitarian 
age,  and  yet  we  find  academic  but  well-meaning  ecclesiastics  who  are  dread- 
fully worried  because  the  rest  of  humanity  have  refused  to  stand  still.  It 
takes  a  public  conscience  to  make  the  individual  one  see  straight.  The  same 
people  who  think  local  option  the  only  righteous  way  may  have  had  grand- 
fathers who  owned  distilleries,  and  those  old  distillers  may  have  prayed  more 
fervently  than  do  their  descendants.  The  public  conscience  is  the  practical 
outcome  of  the  old  saying:  "  The  voice  of  the  people  is  the  voice  of  God." 
Certainly,  the  people  are  demanding  that  better  conditions  as  relates  to  dis- 
ease must  prevail,  or  they  will  hold  the  medical  profession  responsible.  And 
the  people  are  right.  Woe  betide  the  profession,  or  any  part  of  it,  that  fails 
to  heed  the  "  signs  of  the  times." 

Nevertheless,  health  officers  must  be  patient  with  the  men  who  cannot 
see  their  way.  Funerals  bring  lots  of  good  things  to  pass  and  they  are  the 
only  thing  that  will  accomplish  some  reforms.  Ideas  die  more  slowly  than 
do  men,  and  the  mummies  of  some  dead  ideas  are  often  long  kept  on  ex- 
hibition, but  the  public  ultimately  demands  new  sights  and  "  the  mills  of  the 
gods"  gradually  grind  new  grist.  I  know  it  is  aggravating  to  have  to  put  up 
with  the  illogical  opposition  of  touchy  doctors,  but  then  the  health  officer 
himself  may  have  some  little  pet  delusion  of  his  own.  And  sometimes  the 
doctor  is  right. 

To  this  very  day  the  health  laws  of  some  of  the  Southern  states  do  not 
nam.e  the  mosquito  in  connection  with  yellow  fever,  and  thereby  hangs  a  tale. 
Years  ago  some  "  fool  doctors  "  dared  to  claim  that  this  gentle  bird  carried 
the  fever  and  that  such  regulations  as  the  following  were  not  effective: 

MEASURES  TO  BE  TAKEN  IN  A  TOWN  OR  LOCALITY  WHICH  MAY  NOT 
REQUIRE  QUARANTINE 

16.  If  an  inspection  shows  that  the  disease  be  certainly  confined  to  a  few  houses 
and  all  persons  who  have  been  exposed  to  possible  infection  are  known,  and  these 
houses  and  people  be  isolated  under  observation,  the  remainder  of  the  town  need  not 
be  quarantined;  should  either  of  these  conditions  fail  the  town  shall  be  quarantined. 

20.  When  practicable  in  towns  which  do  not  require  quarantine  the  patient  shall 
be  removed  to  hospital  or  other  quarters  little  liable  to  infection,  and  so  situated  as  to 
involve  a  minimum  of  danger  if  infected. 

21.  If  the  patient  cannot  be  removed  all  proper  precautions  must  be  taken  to 
prevent  contamination  of  his  premises. 

22.  Those  immune  to  yellow  fever  and  furnishing  evidence  to  that  effect  satis- 


232  HYGIENE 

factory  to  the  health  officer  in  charge  may  be  given  free  pratique  after  disinfection  of 
effects. 

23.  Non-immunes  may  be  permitted  to  go  to  places  incapable  of  infection,  to 
remain  there  during  the  period  of  incubation,  but  their  baggage  must  be  disinfected 
before  leaving. 

24.  Non-immunes  not  going  to  such  places  shall  be  isolated  under  observation 
in  non-infected  quarters,  so  situated  as  if  fever  develops  among  them  there  shall  be  as 
little  danger  as  possible  of  conveying  infection;  their  effects  being  disinfected  upon 
isolation. 

25.  Such  persons  as  are  isolated  under  observation  on  account  of  exposure  to 
yellov?  fever  shall  be  so  isolated  for  a  period  of  not  less  than  ten  days  from  the  last 
possible  time  of  exposure  to  infection.     They  shall  be  inspected  once  daily. 

26.  Premises  occupied  or  having  been  occupied  by  a  case  sick  with  yellow  fever 
shall  be  treated  as  infected,  and  be  under  sanitary  control,  and  such  neighboring  prem- 
ises as  are  close  enough  for  their  inmates  to  receive  infection  from  the  above,  shall  also, 
with  their  inmates,  be  under  sanitary  control. 

And  much  more  to  like  effect,  even  to  recommending  depopulating  the 
town  as  rapidly  as  possible. 

It  sounds  funny  now,  but  I  remember  the  time  when  it  did  not  sound 
funny,  and  when  the  whole  North  was  frightened  over  the  "  yellow  Jack." 
AncJ  yet  even  some  of  our  most  noted  living  sanitarians  waxed  wroth  and 
indignantly  denied  the  possibility  of  the  despised  mosquito  being  the  agent 
of  dissemination.  And  they  had  two  earthquakes  out  in  San  Francisco;  one 
shook  down  buildings  and  the  other  nearly  blew  up  the  Public  Health  and 
Marine  Hospital  Service  because  the  service  listened  to  other  "  fool  doctors  " 
who  had  noticed  that  bubonic  plague  killed  rats  and  that  rats  had  fleas. 
Things  and  language  looked  blue  out  there  for  a  time,  and  the  local  health 
authorities  "went  up  into  the  air  "  so  high  they  have  not  all  come  down  yet. 
Some  one  has  said  that  "  dogmatism  is  puppyism  grown  up."  Perhaps! 
At  all  events  even  health  officers  should  study  history  before  they  denounce  the 
"  fool  doctors."  A  certain  amount  of  conservatism  and  humility  does  not 
hurt  any  of  us.  Our  sins  are  very  largely  the  sins  of  our  age  and  time,  and 
the  doctors,  take  them  all  and  all,  are  as  good  as  this  age  deserves.  But  a 
better  age  is  coming  and  better  doctors  will  come  with  it,  as  well  as  trained 
local  health  authorities  who  will  master  the  gentle  art  of  making  an  ally  of  the 
doctor. 

The  first  contact  of  the  doctor  with  the  health  officer  usually  is  in  the  form 
of  the  medical  report  of  infectious  disease  occurring  in  his  practice.  Un- 
fortunately very  many  health  boards  fail  to  realize  that  the  doctor  has  limited 
time,  and  cannot  afford  to  employ  a  clerk  to  make  the  free  reports  exacted  of 
him.  These  blanks  are  often  unnecessarily  long  and  even  duplicate  data 
reported  by  the  health  officer.  The  result  of  these  long  blanks  is  that  the  phy- 
sician frequently  fails  to  report  minor  diseases  at  all.  Some  child  may  be 
brought  to  my  office  and  the  cough  prescribed  for  develops  into  whooping 
cough  and  must  be  duly  reported.  When  it  comes  to  filling  out  the  blank 
report  I  find  that  I  must  give  the  full  name,  the  age,  the  number  of  persons  in 
the  family,  their  ages  and  sex,  others  exposed,  etc.     Half  the  time  I  have  never 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  233 

seen  the  persons  before,  and  they  are  two  miles  away  when  I  fill  out  the  blank. 
It  is  true  that  I  should  look  fully  into  these  matters  as  I  go  along,  but  when 
one  gets  small  fees  and  must  push  right  along  to  make  a  fair  living  he  does 
not  have  uppermost  in  his  mind  the  free  reports  he  is  expected  to  make.  It 
impresses  me  that  the  doctor  should  either  be  paid  for  making  the  reports, 
or  they  should  be  of  a  very  brief  nature  and  take  little  of  his  time  to  fill.  The 
mere  name  of  the  patient,  with  the  address,  name  of  disease,  and  date  of 
onset,  will  give  the  health  officer  all  he  needs  to  make  his  first  visit.  This 
officer  should  be  a  physician,  even  if  some  of  the  local  physicians  do  not  like 
another  doctor  going  to  verify  their  diagnoses.  A  medical  health  officer  is 
in  as  good  or  better  position  to  report  to  the  authorities  the  necessary  data 
than  is  the  attending  physician.  The  better  class  of  families  hesitate  to  give 
proper  data  to  an  officer,  other  than  a  physician,  and  they  instinctively  realize 
that  he  will  be  more  considerate  and  less  harsh  than  the  man  they  regard  as  a 
policeman  is  apt  to  be.  Of  course  there  are  harsh  doctors  and  gentle  police- 
men, but  it  is  well  to  be  considerate  of  the  people.  I  have  known  quarantine 
officers  who  were  not  fit  to  quarantine  self-respecting  cattle.  They  were  ap- 
pointed by  a  corrupt  political  machine.  Such  men  are  not  capable  to  fill  the 
office,  and  it  is  an  outrage  to  inflict  them  upon  the  community. 

As  an  illustration  of  the  kind  of  reports  local  health  officers  should  make, 
I  have  asked  the  Michigan  State  Department  of  Health  for  copies  of  their 
blanks  to  reproduce.  The  following  are  a  part  of  the  excellent  set  sent  to 
me.  I  can  recommend  them  as  model  blanks  and  as  serving  the  purpose 
much  better  than  would  those  commonly  filled  out  by  the  attending 
physician. 

FIRST  REPORT  OF  EACH  CASE  OF  DIPHTHERIA,  SCARLET  FEVER, 
MEASLES,  WHOOPING-COUGH,  SMALLPOX 

To  be  mailed  to  the  secretary  of  the  state  board  of  health,  Lansing,  Michigan,  as 
soon  as  the  health  officer  knows  of  there  being  in  any  household  within  his  jurisdiction 
a  first  or  subsequent  case. 
To  the  Secretary: 

Sir:  —  There  has  come  to  my  knowledge  a case  of 

in  the  household  of who  resides  in  the 

of ,  County  of 

State  of  Michigan.     The  name  of  the  person  sick  is a 

taken  sick  with  this  disease  on  the day  of 190 

Has  the  infected  house  been  conspicuously  placarded  ? Has  the  person  sick 

with  this  disease  been  ordered  isolated.? Have  all  per- 
sons exposed  to  the  disease  been  ordered  isolated  ? For  how  long  ? 

Note  : 


Signature Health  Officer  of. 

190 

I  have blanks  like  this. 


234  HYGIENE 

FINAL  HOUSEHOLD  REPORT  RELATIVE  TO  DIPHTHERIA,  SCARLET 
FEVER,  MEASLES,  WHOOPING  COUGH 

This  blank  is  to  be  filled  out  by  the  health  officer  when  the  last  case  in  a  household 
has  recovered  or  died. 

Please  Make  a  Full  Report 

190 

To  the  Secretary  of  the  State  Board  of  Health,  Lansing,  Michigan: 

1.  The  name  of  the  disease  about  which  this  report  is  made  is 

2.  All  cases  included  in  this  report  occurred  in  the  household  of 

who    resides  in  the of County  of 

State  of  Michigan. 

3.  How  was  this  disease  first  introduced  into  this  household  ? 

4.  The  disease  in  this  household  began 190 .  .  .  . ,  ended 190 .  . 

5.  Number  of  cases  occurring  in  this  household  were.  .  .  .Number  of  deaths  were.  . .  . 

6.  Were  the  instructions  of  the  State  Health  Department,  as  contained  in  the  pamph- 
let on  the  restriction  and  prevention  of  this  disease,  promptly  carried  out  relative  to: 

(a)  Thorough  isolation  of  those  sick  or  infected  .''    

(b)  Conspicuous  placarding  of  the  premises  .'' 

(c)  Disinfection  of  discharges  from  mouth,  nose,  and  throat .? 

(d)  Disinfection  of  discharges  from  bowels  and  kidneys  ^ 

"^(e)  Disinfection  of  all  bedding,  clothing,  etc.,  used  by  the  patients  and  attendants  ? 

(f)  Disinfection  of  the  house  and  contents  ^ 


In  cases  of  diphtheria: 

7.  How  many  persons  sick  with  diphtheria  were  treated  with  antitoxin  .? 

8.  On  how  many  persons  exposed  to  but  not  yet  sick  with   diphtheria  was  antitoxin 

used  ? 

9.  Of  the  persons  exposed  to  diphtheria  and  treated  with  antitoxin,  how  many  after- 
wards had  diphtheria  ? 

Remarks  : 


Signature 

,  Mich.  Health  Officer  of. 


FIRST  REPORT  OF  A  CASE  OF  TYPHOID  FEVER 

[To  be  mailed  to  the  secretary  of  the  state  board  of  health,  Lansing,  Mich.,  as 
soon  as  the  health  officer  knows  of  a  case  being  present  in  his  jurisdiction.] 
To  the  Secretary: 

Sir  —  There  has  come  to  my  knowledge  a  case  of  Typhoid  Fever  in  the 

of   

County  of State  of  Michigan.     The  name  of  the  person 

sick  is ,  a 

about years  old,  who  was  taken  sick  with  this  disease  on  the 

day  of ,  190 .  . ,  and  which  case  was 

reported     to     me 190 .  . .     Suspected    source 

of  infection  is 

Have  instructions  been  given  to  disinfect  the  discharges  from  the  body  of  the  patient } 

Has  the  person  sick  with  this  disease  been  ordered  isolated  1 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  235 

How  many  cases  are  now  present  in  your  jurisdiction  ? 

Remarks  : 


Signature  

Health  Officer  of 

190 

I  have blanks  like  this. 

FINAL  REPORT  RELATIVE  TO  A  CASE  OF  TYPHOID  FEVER 

[This  blank  is  to  be  filled  out  by  the  health  officer  and  returned  immediately  after 
the  patient  has  recovered  or  died.] 

Please  Make  a  Full  Report 

190. 

To  the  Secretary  of  the  State  Board  of  Health,  Lansing,  Mich.: 

1.  The  case  reported  occurred  in  the of 

County  of ,  State  of  Michigan 

2.  The  name  of  the  patient  was 

3.  The  age  of  the  person  was years.     The  sex 

4.  The  case  was  taken  sick ,  190 ..  and  died ,  190 . 

or  recovered 190 .  . 

5.  The  disease  was  contracted  in  the  following  manner    

6.  From  what  source  was  the  water  for  domestic  purposes  obtained  .? 

7.  Was  the  water  boiled  during  the  entire  period  of  sickness  of  this  patient  ? 

8.  Were  flies  excluded  from  the  sickroom  .'' 

9.  Were  the  instructions  laid  down  by  this  department,  as  contained  in  the  pamphlet 
on  typhoid  fever,  promptly  carried  out  relative  to: 

(a)  Isolation  of  the  patient  ? 

(b)  Conspicuous  placarding  of  the  premises  ?   

(c)  Disinfection  of  the  discharges  ? 

(d)  Disinfection  of  all  bedding,  clothing,  etc.,  soiled  by  the  patient  f 

(e)  Disinfection  of  the  sickroom  ? 

(f)  Disinfection  of  the  privy  ? 

Signature 

' Mich.  Health  Officer  of 


CONSUMPTION,  PNEUMONIA,  MENINGITIS 
First  Special  Report 

[To  be  mailed  to  the  secretary  of  the  Michigan  Department  of  Health,  Lansing, 
Mich.,  as  soon  as  the  health  officer  knows  of  a  case  being  present  in  his  jurisdiction.] 
To  the  Secretary: 

Sir  —  There  has  come  to  my  knowledge  a  case  of 

in  the of 

County  of State  of  Michigan. 

The  name  of  the  person  sick  is 

a ; years  old.     Color 

Married  or  single Occupation 

Taken  sick  on  the day  of ,  190 .  . 

In  what  part  of  the  body  is  the  disease  located  .? 


236  HYGIENE 

The  number  of  cases  now  present  in  this  same  family  is 

Has  instruction  been  given  regarding  the  destruction  or  disinfection  of  the  sputa 

before  it     has  been  allowed  to  become  dry  ? 

Signature  

Health  Officer  of 

190 

I  have blanks  like  this. 

SPECIAL  FINAL  REPORT  RELATIVE  TO  A  CASE  OF  PNEUMONIA 

[This  blank  is  to  be  filled  out  by  the  health  officer  and  returned  after  the  case  has 
recovered  or  died.] 

Please  Make  Full  Report 

,  190.. 

To  the  Secretary: 

1.  The  case  reported  occurred  in  the of 

County  of ,  State  of  Michigan. 

2.  The  name  of  the  patient  was 

3.  Age Years;  Sex ;  Color ;  Married ; 

Occupation 

4.  The  case  was  taken  sick ,  190 .  .  and  died ,  190 . . 

or  recovered ,  190 .  . 

5.  *^  Was  there  recently  a  previous  case  of  pneumonia  in  this  household  ? If  so, 

when  ? ,   190. . 

6.  Can  this  case  be  traced  to  a  former  case  of  pneumonia  ? 

7.  What  sickness  or  other  predisposing  influence  preceded  this  case  ? 

8.  Were  the  instructions  laid  down  by  this  depart  ment,  as  contained  in  the  pamphlet 

on  pneumonia,  promptly  carried  out,  relative  to: 

(a)  Isolation  of  patient  ? 

(b)  Disinfection  of  the  sputa  f 

(c)  Disinfection  of  all  bedding,  clothing,  etc.,  soiled  by  this  patient's  sputa  ? 

(d)  Disinfection  of  the  sick  room  ? 

Signature  

Mich.  Health  Officer  of 

FINAL  REPORT  RELATIVE  TO  A  CASE  OF  CONSUMPTION 
(TUBERCULOSIS) 

[This  blank  to  be  filled  out  by  the  health  officer  and  returned  after  the  case  has 
recovered  or  died.] 

Please  Make  Full  Report 

190.. 

To  the  Secretary  of  the  State  Board  of  Health,  Lansing,  Michigan: 

1.  The  case  included  in  this  report  occurred  in  the of 

County  of State  of  Michigan. 

2.  The  name  of  this  consumptive  person  was 

3.  The  age  of  the  person  was years.     The  sex Color 

Married The  occupation 

4.  The  case  was  taken  sick ,  190 . . ,  and  died 190 . . 

or  recovered ,  190 . . 

5.  In  what  part  of  the  body  was  the  disease  located  ? 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  237 

6.  Was  this  patient  a  coughing  consumptive  ? 

7.  Was  the  sputa  examined  for  the  Bacillus  tuberculosis  ? With  what  result  ?. . 

8.  Had  or  has  the  patient  any  relative  or  associate  vpho  has  been  or  is  sick  with 
consumption  ? 

If  so,  who  ? When  ? 

9.  Can  you  trace  this  case  to  a  former  case  of  consumption  or  tuberculosis  ? 

10.  Can  you  trace  any  other  case  of  consumption  or  tuberculosis  to  this  case  ?    

11.  Were  the  instructions  laid  down  by  this  department,  as  contained  in  the  pamphlet 
on  tuberculosis,  promptly  carried  out,  relative  to: 

(a)  Disinfection  of  the  sputa  ? 

(b)  Disinfection  of  all  bedding,  clothing,  etc.,  soiled  by  sputa  or  bowel  discharges  ? 

(c)  Disinfection  of  the  bowel  discharges  ? 

(d)  Disinfection  of  the  rooms  occupied  by  the  patient  ? 

Signature 

Mich.  Health  Officer  of 

Other  reports. —  Having  indulged  in  this  little  preachment,  we  come  to  the 
specific  duties  of  the  health  officer.  Our  argument  will  assume  that  he  Is  a 
physician,  and  he  certainly  should  be,  and  the  argument  must  be  general,  since 
conditions  vary  widely.  The  fact  that  a  telephonic  report  is  legal  and  is 
urged  in  the  case  of  smallpox  and  other  severe  diseases  justifies  my  contention 
that  other  less  serious  diseases  may  well  be  reported  in  very  simple  manner. 
The  main  thing  is  to  tell  where  the  patient  is  and  to  put  the  doctor  on  record 
as  to  the  diagnosis.  In  our  consideration  of  these  matters  we  can  well  ignore 
the  members  of  the  board  other  than  the  health  officer,  since  he  does  most  of 
the  real  field  work. 

Having  received  the  report,  the  health  officer  need  not  call  into  question 
the  correctness  of  the  diagnosis  of  the  attending  physician,  but  must  quaran- 
tine at  once.  When  two  attending  doctors  disagree  a  third  one  may  be  called 
and  the  diagnosis  be  determined  by  the  majority,  but  quarantine  may  be 
maintained  until  such  time  as  the  health  officer  may  feel  certain  that  the 
patient  assuredly  does  not  have  the  disease  in  question.  Furthermore,  some 
states  very  properly  expect  a  health  officer  to  investigate  any  suspicious  cases 
not  reported.  To  do  so  effectively  requires  that  the  officer  be  a  physician. 
At  this  point  let  me  quote  from  the  Wisconsin  regulations : 

As  a  matter  of  course,  if  the  health  officer  be  a  physician  his  duty  of  investigating 
the  causes  of  and  circumstances  attendant  upon  the  appearance  of  any  disease  must 
not  be  construed  as  giving  any  authority  to  interfere  with  the  rights  of  the  regular 
medical  attendant  of  the  case,  and  great  caution  must  be  exercised  lest  a  conflict  be 
brought  about  in  the  performance  of  such  a  duty.  In  making  an  investigation  there 
should  be  the  most  cordial  co-operation^and  understanding  between  the  health  officer 
and  medical  attendant. 

In  case  of  epidemic,  emergency  reports  may  be  exacted  of  the  health 
officer.  Most  health  officers  have  weekly  or  monthly  reports  to  render,  and 
the  regular  inspection  reports  upon  the  many  lines  of  work  often  undertaken, 
as  well  as  reports  of  supplies  and  expenditures,  all  tend  to  make  the  word 
*'  report  "  a  tender  spot  with  him. 


238  HYGIENE 

The  up  to  date  health  officer  is  a  very  busy  man  and  must  report  along 
so  many  lines  that  it  would  not  be  profitable  for  us  to  take  up  here  the  details 
of  so  much  clerical  work.  Suffice  it  to  say  that  if  vital  statistics  can  be  cor- 
rectly collected  and  if  health  department  records  are  to  amount  to  much, 
the  trained  health  officer  is  the  only  man  whose  reports  will  bring  about  the 
benefits  that  should  accrue  to  science  from  the  expensive  and  elaborate  work 
of  the  authorities.  All  local  records  are  collated  by  the  state  boards  and 
these  should  be,  in  turn,  by  a  national  one. 

The  inspection  of  hotels  and  public  buildings  is  commonly  a  part  of  his 
work.     It  is  given  a  separate  chapter  in  this  book. 

School  inspection  may  be  delegated  to  the  health  officer,  but  is  becoming 
a  special  line  of  work.     (See  Chapter  III.) 

Penal  institutions  and  hospitals  are  also  given  a  separate  chapter, 
although  the  health  officer  may  have  certain  duties  to  perform  with  reference 
to  them.  Maternities,  places  of  amusement  and  dissipation^  slums,  and  town 
nuisances,  camps,  tuberculosis  sanitaria,  food  and  drug  inspection,  corporation 
property,  and  many  other  subjects  more  or  less  connected  with  the  work  of 
the  health  officer  are  given  full  discussion  in  chapters  devoted  to  them. 

Diagnosis  is  often  a  function  of  the  health  officer.  Permit  me  to  refer  to 
Chapter  XV  upon  infectious  diseases  and  to  Chapter  XXIV  upon  laboratory 
methods. 

Vaccination  and  serum  therapy  is  discussed  in  Chapter  XVI  upon  im- 
munity.    No  data  need  be  given  here. 

Quarantine  is  of  such  importance  that  it  has  a  full  chapter  upon  the 
subject.  In  addition  it  is  necessary  for  the  health  officer  to  be  fully  informed 
as  to  the  regulations  governing  his  own  state  and  district. 

Disinfection  is  so  important  a  subject  to  the  health  officer  that  he  should 
have  a  special  outfit  for  the  work.  The  general  subject  of  disinfection  is 
taken  up  in  Chapter  XVIII.  Most  state  boards  provide  a  uniform  for  the 
health  officer  to  use  when  disinfecting  a  room  or  building.  The  general 
pattern  is  that  of  a  loose  union  garment  made  of  duck  or  other  washable 
material.  A  cloaked  hood  is  worn  upon  the  head  and  rubber  shoes  or  boots 
and  a  pair  of  rubber  gloves  complete  the  outfit.  A  special  formaldehyde  and 
permanganate  bucket  is  advised  by  most  boards.  The  following  directions 
are  from  the  Illinois  regulations: 

The  only  apparatus  required  is  a  large  open  vessel,  protected  by  some  non- 
conductive  material  to  prevent  the  loss  of  heat  from  within.  An  ordinary  milk-pail 
set  into  a  pulp  or  wooden  bucket  will  answer  every  purpose,  although  a  special  con- 
tainer devised  for  physicians  and  health  officers  will  be  found  of  considerable  advan- 
tage. This  container  or  generator  consists  of  a  simply  constructed  tin  can  with  broad, 
flaring  top.  Its  full  height  is  fifteen  and  one  half  inches,  the  height  from  the  bottom 
to  the  flaring  top  being  about  eight  inches.  The  lower  or  round  section  is  ten  inches 
in  diameter,  while  the  flaring  top  is  seventeen  and  one  half  inches  in  diameter  at  its 
top.  The  container  is  made  of  a  good  quality  of  bright  tin,  is  supplied  with  a  double 
bottom,  with  one  fourth  inch  air  space  between  the  two  layers,  and  is  entirely  covered 
on  its  sides  and  bottom  with  asbestos  paper.  The  asbestos  paper  and  double  bottom 
serve  effectively  to  retain  the  heat  which  is  generated  by  the  vigorous  chemical  reaction 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  239 

occurring  within  and  which  is  essential  to  the  complete  production  and  liberation  of 
the  gas.  This  special  container  can  be  made  by  any  tinner  of  ordinary  intelligence 
and  costs  but  a  few  dollars. 

Rural  health  officers  should  read  Chapter  VIII,  which  also  covers  the 
question  of  milk  inspection  and  the  sanitation  of  dairies  and  creameries. 

The  relationship  to  the  coroner  is  given  in  Chapter  XIII. 

Epidemics  are  discussed  in  Chapter  XVII. 

Funerals  and  the  regulations  concerning  dead  bodies  are  sometimes 
matters  of  local  legislation.  The  chapter  upon  disinfection  touches  upon  the 
question,  and  those  upon  the  coroner  and  upon  corporations  give  some  atten- 
tion to  the  matter.  The  supplying  of  nurses  demands  appropriation?, and  the 
health  officer  should  be  guided  by  the  instructions  of  the  board. 

A  study  of  the  several  chapters  to  which  attention  has  been  called  will 
give  a  health  officer  a  good  idea  of  his  general  duties,  but  the  necessity  of  in- 
forming oneself  regarding  local  regulations  remains  and  should  not  be  ne- 
glected. Probably  enough  was  said  earlier  in  this  chapter  to  emphasize  the 
necessity  of  adhering  strictly  to  the  law.  It  must  be  remembered  by  the 
health  officer  especially,  that  he  takes  an  oath  to  uphold  the  laws  and  regu- 
lations. Personally  I  detest  military  methods  and  routine,  but  I  know  per- 
fectly well  that  they  are  an  absolute  necessit)  in  many  of  the  relations  of  life 
and  even  in  the  sanitary  service.  I  have  no  right  to  let  my  personal  dislikes 
make  me  break  the  laws  or  interfere  with  discipline.  I  know  that  there  are 
hosts  of  good  soldiers  who  dislike  the  discipline  and  routine  most  heartily 
and  yet  these  same  men  obey  every  order.  The  health  officer  should  never 
question  necessary  regulations.  But  he  has  a  place  in  creating  or  changing 
merely  local  regulations. 

The  relationship  to  the  physician  has  been  discussed  to  some  extent,  but 
a  word  must  be  s^id  as  to  sectarian  physicians.  The  laws  of  the  states  provide 
for  boards  of  examiners  before  whom  all  physicians  who  desire  to  practice  in 
the  state  must  come.  All  who  pass  the  board,  regardless  of  school,  are  equal 
before  the  law.  It  is  not  incumbent  upon  a  health  officer  to  raise  any  questions 
as  to  the  school  or  the  special  therapeutics  of  the  physician.  Frcin  the  sani- 
tary standpoint  all  schools  think  about  alike,  and  the  question  of  sectarian 
medicine  need  not  enter  into  the  account.  Occasionally  extremists  of  some 
schools  will  raise  questions  well  answered  by  merely  referring  to  the  statutes 
and  the  regulations.  Attenuated  vaccine  virus  given  internallv  is  advocated 
by  a  mere  handful  of  men.  In  the  meaning  of  most  acts  or  statutes  such 
administration  is  not  vaccination,  and  no  evidence  can  be  had  of  whether  or 
no  it  "  takes  "  or  becomes  effective.  Hence,  the  officials  will  not  accept  such 
vaccination.  The  question  of  death  certificates  is  one  for  the  coroner  in 
many  cases.  Whether  an  osteopath  or  a  Christian  Scientist  can  give  a  death 
certificate  depends  wholly  upon  the  laws  under  which  he  may  practice.  They 
vary  in  different  states.  The  question  of  obstetric  reports  is  locally  regu- 
lated nearly  ever}'where  and  is  discussed  in  other  portions  of  this  book. 

"  Nuisances  "  might  be  the  subject  for  a  really  humorous  essay,  and  I 
felt  tempted  to  try  my  hand  at  it  since  the  differing  laws  and  conceptions  of 


240  HYGIENE 

what  constitutes  a  *'  nuisance  "  are  as  hard  to  put  together  as  a  jigsaw  puzzle. 
They  range  all  the  way  from  dead  animals  in  Kansas  wells  to  crowing  roosters 
in  the  District  of  Columbia,  and  embrace  almost  everything  in  between. 
First,  find  your  alleged  nuisance  and  then  report  it  to  the  president  of  the 
board  of  health.  He  will,  in  turn,  report  it  to  the  third  assistant  district 
attorney.  In  due  time  it  comes  to  the  ears  (or  nose)  of  the  district  attorney, 
who  refers  it  to  the  city  solicitor.  He  decides  that  action  may  be  brought. 
The  president  of  the  board  decides  that  no  funds  exist  for  the  bringing  of  the 
action,  and  calls  it  to  the  attention  of  the  grand  jury.  They  orate  about  it, 
but  decide  that  it  is  in  the  city  and  therefore  not  within  the  province  of  a 
county,  and  it  gets  to  city  councils.  They  refer  it  to  their  legal  adviser  who 
finds  the  ordinance  upon  nuisances  defective.  They  make  a  new  ordinance, 
but  the  old  health  officer  has  died  meanwhile  and  the  formerly  rich  owner  of 
the  property  harboring  the  nuisance  has  lost  his  money.  Meanwhile  again,  a 
raw  policeman  who  has  a  hard  fist  and  knows  how  to  swear,  has  not  bothered 
about  technicalities  and  ripped  it  out  on  sight  and  promised  to  "  make  it  hot  " 
for  the  owner  if  the  nuisance  is  repeated.  Health  officers  need  the  "big 
stick  "  in  abating  some  nuisances. 

Joking  aside,  what  I  have  said  very  nearly  covers  the  ground.  The  fact 
that  the  health  officer  considers  any  given  thing  or  condition  a  nuisance 
does  not  legally  make  it  so.  The  law  is  exceedingly  potent  in  conserving  the 
rights  of  property  and  very  slow  in  abrogating  or  denying  any  of  those  rights. 
Whether  rightly  or  wrongly,  courts  are  actuated  largely  by  precedents  and 
the  common  law  in  determining  equities  and  disabilities  not  defined  by  statute 
or  ordinance,  and  juries  are  not  inclined  to  take  from  an  individual  anything 
demanded  by  the  state  unless  the  state  pays  two  or  three  prices  therefor.  In- 
junctions are  easy  to  get  and  hard  to  dissolve,  and  some  recalcitrant  offender 
against  sanitation  can  hang  up  a  health  officer  almost  indefinitely  when  it 
comes  to  matters  involving  property.  Juries  go  more  by  the  witnesses  or 
evidence  than  they  do  by  the  court  and  the  law.  For  instance,  the  health 
officer  declares  an  infected  vault  a  nuisance  and  orders  its  removal.  The 
owner  does  not  comply  with  the  order  and  the  board  of  health  enters  a  com- 
plaint before  a  court.  The  medical  evidence  is  clear  to  a  medical  man,  but 
not  to  a  jury  or  a  judge.  The  attorney  for  the  defence  brings  a  number  of 
witnesses  having  vaults  of  their  own,  and  none  of  them  know  of  any  person 
being  injured  in  his  comfort  or  in  the  enjoyment  of  his  estate  by  reason  of  the 
vault  in  question. 

It  is  only  by  virtue  of  the  police  power  that  the  state  can  control  certain 
nuisances  involving  property.  Wells,  slaughter  houses,  offensive  manufac- 
turing, a  stagnant  mill  pond,  stored  manure,  swine  near  to  a  schoolhouse,  a 
saloon  adjoining  a  church,  a  private  sewer,  and  many  other  things  may  be 
declared  nuisances  when  a  bill  in  chancery  is  filed  and  a  judicial  decision  is 
reached,  but  the  chances  are  that  if  they  seriously  injure  some  man's  business 
or  property  interests,  the  courts  will  fail  to  decide  in  favor  of  the  health  officer 
or  the  board  of  health. 

On  the  principle  that  due  notice  of  intention  constitutes  a  certain  legal 
bar  to  prevent  a  man  investing  money  in  projects  apt  to  be  later  declared 


FIRST     FLOOR     PLAN 


PUBLIC    COMFORT    STATION,    WASHINGTON,    D.  C. 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS 


241 


Public  Comfort  Station,  IVashington,  D.  C. 


242  HYGIENE 

nuisances,  it  is  good  policy  for  local  boards  of  health  to  define  regulations  gov- 
erning certain  industries  and  occupations  liable  to  produce  nuisances  and  to 
declare  the  intention  to  ask  for  legislation  from  councils  preventing  certain 
things  after  some  date  announced.     (See  Appendix.) 

Local  responsibility  is  not  sufficiently  apprehended  by  many  counties  and 
cities.  It  is  not  the  intention  of  the  state  boards  to  take  things  out  of  local 
hands,  any  more  than  it  is  the  desire  of  the  state  school  department  to  abolish 
local  boards  of  directors. 

Bacteriologists  and  chemists  are  employed  by  many  of  the  state  boards 
and  by  the  larger  cities.  The  health  officer  should  make  use  of  these  experts 
rather  than  to  rely  upon  his  own  tests.  It  is  not  very  practical  for  one  man 
to  keep  up  a  bacterial  incubator  and  fresh  culture  media  and  all  the  more  or 
less  perishable  reagents  and  stains  needed  in  modern  laboratory  work.  If  he 
undertakes  to  do  so  he  is  apt  to  neglect  the  field  or  clerical  work. 

Ideals  are  often  hard  of  attainment  but  should  be  indulged  more  or  less. 
The  special  medical  inspector  of  Louisiana  divides  his  work  under  the  follow- 
ing headings: 

A.  Educational:  Hygienic  Institute  work. 

B.  Convention  work. 
V  C.     Office  work. 

D.  Legislative  work. 

E.  Field  work. 

This  active  officer  held  over  one  hundred  institutes  in  schools  and  other 
public  buildings,  and  expounded  the  mosquito  control  idea  and  other  sanitary 
measures  all  over  the  state.  Certain  social  features,  as  a  barbecue,  helped 
along.  Chautauquan  lectures  were  given  and  conventions  of  health  officers 
were  held,  and  all  this  stimulated  the  local  health  officers  to  do  the  office  and 
field  work  more  effectively. 

A  very  important  duty  of  the  health  officer  is  to  educate  the  physicians. 
Publicity  and  education  are  the  two  main  factors  that  have  made  modern 
sanitation  possible.  It  is  natural  for  the  doctor  to  be  so  taken  up  with  his 
cares  that  he  fails  to  appreciate  his  duty  to  the  public  in  the  matter  of  sani- 
tation, and  yet  if  he  is  approached  in  a  fraternal  spirit  and  the  health  officer 
places  in  his  hands  some  of  the  excellent  literature  issued  by  the  boards  he 
may  become  an  enthusiastic  supporter  of  every  sensible  measure.  Health 
officers  should  welcome  opportunities  to  address  medical  societies. 

The  separate  problem  of  cities. —  Some  of  the  cities  have  been  long  organ- 
ized and  the  reports  of  their  health  bureaus  indicate  a  large  degree  of  effi- 
ciency. The  large  eastern  cities  have  elaborate  departments  and  abundant 
regulations.  The  articles  of  the  civil  code  relating  to  sanitation  in  the  city 
of  New  Orleans  take  up  one  hundred  and  seventy  large  pages.  The  bureau 
of  health  of  Philadelphia  undertakes  an  elaborate  work  similar  to  that  of  sev- 
eral other  cities  in  the  East.  Baltimore  has  been  remiss,  but  in  going  through 
the  district  ravaged  by  fire  a  few  years  ago  I  found  as  up  to  date  and  sanitar}' 
business  blocks  as  one  will  find  in  any  part  of  the  country  and  the  city  is  putting 
in  a  most  complete  sewage  system.  It  and  San  Fiancisco  are  illustrations  of 
what  a  great  disaster  will  do  to  stimulate  a  city  to  better  things,  and  give  the 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  243 

sanitarians  a  chance  to  do  things  the  previous  inertia  would  never  allov/. 
Even  China  Town  in  the  latter  city  is  growing  up  from  the  ashes  a  thing  of 
beauty  and  cleanliness.  I  was  recently  in  Cleveland  and  find  it  a  fair  illus- 
tration of  the  good  work  being  done  by  cities  of  its  class  all  over  the  land. 
My  own  little  city  is  rapidly  becoming  a  model  of  cleanliness  and  has  gone 
about  the  matter  in  a  very  scientific  way.  Chicago  and  all  of  the  cities  along 
the  great  lakes  are  fully  awake.  The  commissioner  of  the  department  of 
health  of  the  city  of  Chicago  showed  the  Western  spirit  when  he  said,  in  the 
Bulletin  Chicago  School  of  Sanitary  Instruction,  for  February  20,  1909, 
speaking  of  annual  reports:  "  Essays  on  sanitary  questions  are  buried  when 
placed  in  an  annual  report.  .  .  .  They  should  be  published  in  widely  circu- 
lated periodicals,  and  should  come  to  the  eye  of  sanitarians  when  warm."  So 
the  Chicago  board  publishes  them  weekly  and  has  a  school  to  train  its  men. 
In  general,  the  cities  are  doing  an  excellent  work. 

It  is  necessary  to  end  this  chapter  with  some  exemplifications  of  local 
regulations.  It  was  with  difficulty  that  I  could  select  cities  for  illustration, 
since  so  many  have  excellent  health  laws.  But  because  it  is  the  national  capi- 
tal I  will  outline  the  regulations  of  the  District  of  Columbia  and  the  city  of 
Washington  and  of  New  York  city,  the  largest  city  department.  Additional 
reasons  for  using  Washington  as  an  illustration  are  that  the  city  is  under  civil 
service  regulation  and  the  laws  are  not  twisted  by  the  politician,  and  they 
especially  serve  our  purpose,  since  they  are  for  the  whole  district  and  embrace 
semi-rural  as  well  as  metropolitan  practice. 

No  effort  will  be  made  to  define  the  statutes,  but  to  give  an  alphabetical 
list  of  subjects,  followed  by  a  plain  statement  of  the  regulations  governing 
them..  The  whole  will  serve  as  suggestive  to  other  municipalities  desiring 
changes  in  their  regulations.  However,  it  must  not  be  forgotten  that  con- 
stitutional reasons  may  exist  in  any  specific  state  rendering  some  of  the 
Washington  regulations  beyond  the  reach  of  the  state.  No  regulations  should 
be  drawn  without  legal  advice. 

Advertismg  of  legal  notices,  such  as  the  abatement  of  nuisances  and  the  provision 
of  water  and  sewer  service,  is  provided  in  case  party  or  his  agent  cannot  be  found. 

Ailanthus  trees,  which  emit  a  disagreeable  smell,  are  legally  declared  nuisances 
and  may  not  be  planted. 

Alleys  may  be  closed,  opened,  straightened,  or  divided  among  the  owners  of 
abutting  property,  according  to  facts  as  ascertained  and  the  requirements  of  public 
health.  Refuse  may  not  be  deposited  in  alleys.  Provision  is  made  requiring  further 
building  upon  alleys  to  be  so  placed  as  to  widen  the  alley,  the  idea  being  that  all  alleys 
will  become  narrow  streets  with  adequate  sidewalks  in  time. 

Anatomical  material  is  provided  from  the  almshouse,  etc.,  under  a  defined  ordi- 
nance. 

Animals  may  not  run  at  large.  Animals  sick  with  contagious  disease  may  be 
quarantined  or  killed.  Dead  animals  may  not  be  deposited  in  the  waterways,  the 
streets  or  sewers,  and  must  be  disposed  of  as  directed  by  the  health  officer.  Owners 
of  dead  animals  must  give  notice  to  health  board  within  eight  hours.  Bodies  must  be 
removed  in  covered  wagons  by  the  contractor  who  collects  garbage.  Domestic  ani- 
mals may  not  run  at  large  and  may  be  subject  to  license  or  quarantine.     Cattle  may 


244  HYGIENE 

be  driven  only  upon  certain  streets.  All  manner  of  inspection  of  diseased  animals 
and  the  flesh  of  those  killed  for  food  is  made.  Diseased  cattle  prohibited  in  dairy 
stables.     Unlicensed  animals  impounded. 

Anthrax    in    animals    under    quarantine   regulations   and   milk  from  infected 
animals  may  not  be  sold. 

Antidote  must  be  printed  upon  poison  labels. 

Anti-Narcotic  Law,  very  rigid  provisions  inclusive  of  prescriptions fornarcotics 
to  addicts. 

Antitoxin,  sale  and  purity  under  rigid  regulation. 
Apartment  house  quarantine  may  apply  to  but  a  part  of  building, 
Areaways  must  be  drained. 

Ashes  collected,  sifted,  or  disposed  of  according  to  regulation. 
Barbers  and  shops  regulated  in  every  way  tending  to  prevent  the  patron  from 
infection. 

Bathing  beaches  strictly  regulated. 

Births  reported  under  regulations  to  make  vital  statistics  accurate. 
Blacksmith  shops  regulated  as  to  location,  etc. 

Boarding  houses  regulated  as  to  contagious  diseases,  sanitation,  and  quality  of 
food,  etc. 

Boards  for  condemnation  of  insanitary  buildings,  for  dental,  medical,'and  phar- 
maceutical examination,  for  medical  supervision,  and  for  the  manufacture  of  serums, 
viru'ses,  etc. 

Bones  —  boiling,  burning,  transporting,  and  storage  regulated. 
Bread  regulated  as  to  baking,  adulteration,  etc. 
Building  laws,  detailed,  and  buildings  inspected. 
Bureau  of  Animal  Industry  has  many  regulations. 
Burial  requires  permit  and  cemeteries  regulated. 
Butter  —  making  of  and  sale  regulated.     Standards  required. 
Candy  is  made  and  sold  under  adequate  protection  to  buyer. 
Carpets  and  rugs  may  be  cleaned  only  in  designated  manners  and  places. 
Cars  a  nuisance  if  kept  standing  in  city  loaded  with  manure  or^other^ofFensive 
matter.     Spitting  in  cars  prohibited. 
Cattle  regulated  in  every  way. 
Cellars  may  not  be  used  as  dairies. 
Cemeteries  under  strict  control. 

Cesspools  nearly  prohibited  and,  where  allowed,  must  conform  to  strict  regulation. 
Chemicals,  vending  and  peddling  regulated. 
Cisterns  may  not  be  left  uncovered. 
Combustibles  sold  and  stored  under  regulation. 
Condemnation  of  insanitary  buildings  provided  for. 
Contagious  diseases  reported,  quarantined,  etc. 
Convenience  stations  provided  and  regulated. 
Cremation  regulated. 
Dairies  regulated  in  every  way. 
Dead  bodies  —  adequate  regulation. 
Deaths  registered  and  reported. 
Disinfection  at  public  cost. 

Disinterment  only  on  permit  or  by  order  of  coroner  or  court. 
Dispensaries  must  have  an  isolation  room. 
Docks  may  not  deposit  refuse  in  river. 
Dogs  taxed  and  many  provisions  concerning. 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS     .         245 

Drainage  applied  not  only  to  sewers,  but  to  lots,  parks,  dairy  farms,  and  area  ways. 

Drivers  —  liability  of  defined. 

Drug  addicts  restrained  as  to  sale  of  narcotics. 

Drug  adulteration  —  provisions  practically  those  of  Food  and  Drug  Act. 

Dumps  —  public,  provided  for  and  regulated. 

Dust  may  be  a  nuisance  when  so  declared.     Must  be  kept  in  check. 

Dye  water  must  not  be  run  upon  streets  or  alleys. 

Eating  houses  specifically  regulated. 

Embalming  under  permit  and  regulations. 

Excavations  regulated  and  dangerous  ones  protected. 

Excreta  disposal  only  according  to  regulation. 

Expectoration  regulated.     Prohibited  cars  and  pavement. 

Explosives  —  partial  prohibition. 

Factory  inspection,  regulation,  etc.,  extensive  requirements. 

Fish  markets  regulated. 

Foods  —  requirements  practically  those  of  Pure  Food  and  Drug  Act. 

Fowls  —  May  not  run  at  large,  noisy  fowls  a  nuisance  in  thickly  populated  dis- 
trict, prohibited  in  dairy  stable,  sale  regulated. 

Fruit  —  sale  of  regulated,  unlawful  to  deposit  on  streets  orstreams,  receptacles  on 
streets  for  fruit  skins,  etc. 

Game  —  season  defined,  sale  regulated,  game  warden  provided. 

Garbage  collection  by  contract. 

Garbage  receptacles  of  specified  kind  and  size. 

Gases  —  illuminating,  factory,  sewer,  etc.,  regulated. 

Goats  not  allowed  at  large,  prohibited  in  dairy  stables. 

Grading  with  offensive  substances  prohibited. 

Graves  —  many  requirements. 

Gristmills  only  in  certain  locations. 

Groceries  —  inspected. 

Gutters  —  provisions  for  cleaning. 

Harbor  regulation  act. 

Health  department  vehicles  have  right  of  way. 

Health  officer  —  duties  defined. 

Hides  sold  and  handled  under  regulation. 

Hogs  —  inspection,  keeping,  feeding,  slaughtering,  etc.,  regulated. 

Homoeopathic  pharmacies  defined  and  regulated  by  board. 

Horses  and  stables  regulated.     Horses  not  permitted  in  dairy  stables.     Not 
allowed  to  run  at  large. 

Hospitals  inspected  and  under  regulation. 

Hotels  inspected  and  must  be  sanitary. 

Impersonation  of  health  inspectors  illegal. 

Infected  premises  may  not  be  rented  until  disinfected. 

Insecticides  —  sale  regulated. 

Inspections  of  varied  character.     Many  inspectors. 

Irrigation  —  subsoil  sewage  disposal  in  suburbs. 

Isolation  regulations  for  contagious  diseases. 

"Jails  —  sanitary  regulations  for. 

Labels  must  tell  the  truth. 

Lands  and  tenements  —  several  ordinances  regarding.     Nuisances  of. 
Licenses  of  various  kinds  provided  for. 
Liquors  come  under  Food  and  Drug  Act. 


246  HYGIENE 

Live  stock  —  inspection   provided. 

Lodging  houses  regulated  in  sanitary  directions. 

Manure  —  kept  in  pits,  transportation  regulated. 

Marine  products  —  inspection  provided. 

Measures  —  a  sealer  appointed. 

Medical  inspectors  for  schools,  etc. 

Medical  supervisors  attending  to  the  distribution  of  anatomical  material,  etc. 

Medicines  —  Pure  Food  and  Drug  Act  applying. 

Midwives  registered  and  practice  regulated. 

Milk  —  all  proper  regulation  of  dairies  and  sale  of  milk,  etc. 

Morgue  regulations. 

Narcotics  —  sale  regulated  and  limited. 

Night  soil  disposition  under  regulation. 

Noises  —  loud  and  unnecessary  noises  prohibited. 

Nuisances  —  Many  defined  and  abatement  of  provided  for. 

Nurses  —  registered  and  practice  regulated. 

Odors  —  certain  ones  declared  nuisances. 

Oil  business  regulated. 

Offal  and  offensive  matter  —  regulated  disposition  of. 

Outhouses  to  be  kept  clean  and  wholesome. 

Overcrowding  of  buildings  prohibited. 

Paper  —  may  not  be  thrown  upon  streets.     Circus  paper  to  be  removed. 

Parrots  —  noisy  ones  not  permitted  in  city. 

Permits  —  many  kinds  required. 

Pharmacopoeia  (U.  S.)  official  in  city  regulations. 

Pharmacy  must  be  licensed. 

Physicians  must  report  as  required.     Testimony   privileged. 

Pigeons  —  permit  to  keep  live. 

Plumbing  inspector  working  under  detailed  regulations. 

Police  regulations  —  many  apply  to  sanitation. 

Poisons  —  sale  of  strictly  regulated. 

Poundmaster  with  specified  duties. 

Prescriptions  —  writing  and  compounding  of  regulated. 

Privy  —  many  regulations. 

Public  assemblage  regulated  in  time  of  epidemic,  etc. 

Public  conveyances  regulated. 

Public  schools  —  medical  inspection  of. 

Push  carts  licensed. 

Quarantine  regulations  very  full. 

Rags  dealt  in  and  stored  under  limitations. 

Railroads  —  many  requirements. 

Refuse  disposal  provided. 

Rendering  establishments  regulated. 

Reservoirs  —  sanitary  regulation  of. 

Saloons  come  under  food  and  drink  regulations. 

Schools  —  many  regulations. 

Sewers  —  an  extensive  list  of  regulations. 

Slaughter  houses  carefully  regulated. 

Smoke  nuisance  regulated  and  partly  suppressed. 

Spitting  prohibited. 

Spring  —  unlawful  to  defile. 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  247 

Stables  —  many  provisions  for  sanitation  of 

Stalls  and  stands  must  be  kept  clean. 

Stores  must  be  hygienic. 

Street  cleaning  under  rigid  rules. 

Swill  —  use  regulated. 

Tenements  —  under  inspection  and  sanitary  rules. 

Undertakers  registered  and  under  code  of  rules. 

Urinals  —  sanitary  requirements. 

Vaccination  provided  for. 

Vegetables  sold  and  conveyed  under  regulation. 

Vehicles  licensed  and  under  sanitary  rules. 

Ventilation  subject  to  inspection. 

Veterinary  practice  regulated. 

Vital  statistics  carefully  collected. 

Water  supply  —  an  elaborate  code  of  rules. 

Water  closets  must  be  properly  constructed  and  maintained. 

Weeds  must  be  removed. 

Wharf  inspection  provided. 

What  is  here  given  is  little  more  than  an  index  of  the  more  important 
regulations  of  the  city  and  district,  but  will  serve  as  a  list  of  the  many  phases 
of  sanitation  of  direct  interest  to  the  public  health  officer.  Other  places  have 
still  other  problems  as,  for  instance,  the  mosquito  work  in  the  gulf  coast  cities. 
The  Washington  list  may  be  of  interest  to  gentlemen  who  feel  their  own  city 
regulations  to  be  inadequate.  Municipalities  wishing  copies  of  the  regula- 
tions of  any  city  will  find  them  easy  to  secure  if  they  let  it  be  known  why  they 
are  wanted. 

The  New  York  City  Department  oj Health. —  Having  discussed  the  health 
organization  of  the  District  of  Columbia  and  the  city  of  Washington,  with  the 
maze  of  regulations  and  detailed  specifications  incident  to  that  type  of  health 
administration,  we  will  take  up  quite  a  differently  organized  department  of 
health  and  use  it  to  point  the  moral  the  present  writer  takes  the  liberty  of  de- 
riving from  the  mixed  state  of  affairs  resulting  in  the  United  States  in  a  host 
of  very  defective  local  health  boards.  This,  in  many  respects  the  most  impor- 
tant  health  unit,  is  usually  so  inadequate  in  its  organization  as  to  be  entirely 
echpsed  by  the  state  boards  having  jurisdiction  over  it  and  its  work.  As  has 
been  shown,  the  fault  lies  mostly  with  the  communities  and  their  local  boards. 
In  our  argument  in  favor  of  better  local  boards,  we  bespeak  for  them  a  greater 
legal  latitude.  Some  local  boards  have  been  born  with  so  much  legal  rope 
that  they  have  hung  themselves;  some  have  had  so  much  power  thrust  upon 
them  that  they  got  drunk;  others  have  achieved  power.  To  this  latter 
class  belongs  the  New  York  City  Department  of  Health,  an  organization  that 
has  done  well  and  made  a  name  for  itself  for  the  same  reason  that  the  man 
who  makes  his  own  money  spends  it  more  wisely  than  does  his  neighbor  who 
inherits  a  fortune. 

The  government  of  New  York  city  costs,  according  to  General  Theodore 
Bingham,  ^200,000,000  a  year,  or  one  third  as  much  as  the  expenses  of  con- 
ducting the  entire  federal  government.  Of  this  sum  $156,545,148  is  raised 
by  direct  taxation,  the  balance  being  accrued  bonded  indebtedness. 


248  HYGIENE 

One  and  one  half  per  cent  for  health  administration  is  a  very  modest 
allowance,  and  is  very  much  less  than  is  the  percentage  allowance  of  many 
states  and  cities  for  the  same  purpose.  At  an  assessment  of  twenty  mills,  that 
means  less  than  one  third  mill  for  health  insurance,  and  yet  in  New  York  city 
that  totals  about  $3,000,000  per  year  or  twice  as  much  as  is  received  by  the 
Pennsylvania  Department  of  Health  for  its  work  all  over  the  state. 

But  there  is  a  big  work  to  do  in  Greater  New  York,  it  takes  big  men  to 
do  this  work,  and  it  is  done  in  a  big  way.  Like  such  things  generally,  it  is 
done  economically,  and,  possibly  aside  from  federal  administration,  I  have 
not  personally  seen  anj^where  else  so  much  accomplished,  dollar  for  dollar,  in 
city  administration. 

There  are  few  regulations.  That  should  delight  the  soul  of  President 
Taft,  who  thinks  we  make  too  many  laws.  Of  course  the  New  York  depart- 
ment is  based  upon  law,  but  it  is  in  such  a  hurr}'  to  keep  up  with  its  work  that 
its  regulations  practically  are:  "  We  expect  every  man  to  do  his  duty,"  and 
the  commissioner  sees  to  it  that  the  rule  is  obeyed.  He  is  given  very  full 
powers,  subject  to  revision  by  the  courts.  As  Dr.  Thomas  Darlington,  the 
present  able  commissioner,  is  a  man  of  judicial  temperament,  as  well  as  an 
energetic  officer,  the  people  of  New  Y'ork  city  know  by  experience  that  an 
order  from  his  office  stands  very  remote  chances  of  being  held  up  by  a  court. 

That  New  York  city  has  health  laws  that  are  enforced  is  witnessed  by 
the  fact  that  nine  to  ten  thousand  convictions  for  their  violation  is  a  common 
yearly  record,  and  as  much  as  twelve  thousand  tons  of  bad  foodstuffs  have 
been  destroyed  in  the  same  inters^al;  but  mere  regulations  are  more  a  matter 
of  routine  orders  than  of  the  printed  page. 

It  is  a  fact  that  there  are  boards  of  health  in  certain  portions  of  the 
United  States  operating  under  regulations  adopted  before  formaldehyde 
fumigation  was  in  use,  before  mosquitoes  were  known  to  disseminate  yellow 
fever,  and  long  before  bubonic  plague  touched  our  shores.  It  does  seem  that 
in  these  days  of  rapid  advance  it  is  a  mistake  to  handicap  sanitary  work  with 
regulations  apt  to  be  defective  before  the  ink  is  dr}'.  While  law  is  necessary 
for  the  basis  of  any  sanitary  organization,  it  is  practically  impossible  for  a 
state  board  of  health  to  adopt  regulations  czvry'mg  more  weight  than  mere 
suggestion.  Rural  districts  and  the  cities  of  different  class  cannot  do  good 
work  under  the  same  common  specifications;  yet  it  is  attempted  in  several 
states. 

There  is  no  lack  of  eminent  sanitarians  who,  while  they  uphold  a  state 
law  governing  all  sanitation  within  the  state,  yet  uphold  local  autonomy  in 
many  matters.  From  my  own  pretty  widely  spread  observation,  I  find  that 
trained  men  can  make  better  regulations  than  can  be  made  for  them,  but 
where  the  local  health  board  is  selected  regardless  of  training  specifically 
fitting  them  for  the  work,  it  is  necessary  for  the  state  board  to  provide  specifi- 
cations or  go  into  the  communities  and  do  the  work  themselves.  New  York  city 
is  a  brilliant  example  of  the  fact  that  the  health  unit  (the  local  board)  needs 
trained  men  and  few  regulations  rather  than  one  brilliant  man  presidingover 
the  state  board  and  wearing  his  soul  out  in  the  effort  to  keep  a  lot  of  incompe- 
tent appointees  up  to  the  standard  of  what  a  real  health  officer  should  be. 


BOARDS  OF  HEALTH  AND  SANITARY  OFFICERS  249 

The  New  York  Department  Annual  Reports  are  very  elaborate  and  the 
details  of  their  work  far  too  extended  to  justify  taking  space  here  to  present 
a  descriptive  article.  Their  literature  presents  so  much  of  practical  admin- 
istration and  original  research  that  the  data  is  frequently  used  in  the  various 
chapters  of  this  present  book.  But  it  is  our  present  purpose  to  refer  to  some 
general  principles  proper  to  this  chapter  upon  local  boards  of  health,  and  par- 
ticularly as  relating  to  the  city  problem. 

Firstof  all,  writers  of  fiction  and  near-fiction  have  exploited  New  York  city 
with  an  eye  to  literary  effect  rather  than  telling  the  truth.  There  has  to  be  a 
goat  and  New  York  serv^es  the  purpose.  As  a  matter  of  fact,  the  town  is  no 
better  and  no  worse  than  are  hosts  of  small  cities  more  obscure,  and  New  York 
has  no  copyright  upon  crooked  politics,  low  dives,  immorality,  frenzied  finance, 
or  talent.  It  has  both  the  vices  and  the  virtues  of  the  big.  As  is  to  be  ex- 
pected, the  sanitary  problem  is  a  very  big  one.  The  town  is  the  greatest  for- 
eign missionary  station  in  the  world  and  is  the  greatest  teacher  of  sanitary 
decency  in  this  country.  They  begin  with  the  foreigner  there  in  the  rough 
and  send  him  over  the  rest  of  the  country  better  trained  in  sanitation  than  are 
most  of  the  foreign  residents  of  righteous  interior  towns  whose  residents  go 
to  New  York  for  a  fling  and  find  the  stage  and  slums  there  cleaner  than  they 
are  at  home. 

I  made  a  sanitary  tour  of  the  densely  crowded  "  East  Side,"  and  it  is 
apparent  that  rigid  sanitary  policing  of  the  district  is  imperative.  One  can- 
not temporize  with  those  people,  and  I  found  them  more  afraid  of  the  sanitary 
ofiicer  than  they  are  of  the  police  magistrate.  And  the  sanitary  conditions 
are  far  better  than  the  majority  of  the  country  will  believe.  It  is  to  the  credit 
of  the  department  that  moral  conditions  are  improving  there  in  direct  pro- 
portion as  sanitation  has  been  advanced. 

In  the  chapter  upon  the  sanitation  of  corporate  establishments,  the  point 
is  made  that  the  states  placing  factory  inspection  and  pure  food  work  under 
the  boards  of  health  are  securing  better  results  than  where  separate  boards 
or  departments  do  the  work.  New  York  city  is  a  good  example.  It  patterns 
somewhat  after  the  New  England  states  in  its  factory  inspection.  Nowhere 
else,  not  even  in  Washington,  do  I  find  such  efficient  administration  of  the 
food  laws.  In  both  cities  I  have  banqueted  in  the  cheapest  restaurants  I 
could  find,  and  I  do  not  know  of  any  place  of  five  thousand  people  where  one 
can  get  so  much  clean  and  healthy  food  for  fifteen  cents  as  is  served  in  New 
York  city.      Cleveland,  Ohio,  is  a  close  second, 

I  wish  to  commend  the  series  of  municipal  and  health  department  hos- 
pitals of  New  York  city.  The  reports  show  that  their  maintenance  is  an 
expensive  matter,  but  that  is  probably  balanced  by  the  actual  isolation  of 
communicable  disease  difficult  or  even  impossible  of  attainment  by  other 
means.  Quarantine  is  only  a  relative  term,  and,  under  the  present  social  and 
industrial  conditions,  the  family  doctor  and  the  local  board  of  health  cannot 
make  it  a  positive  one. 

The  division  of  laboratories  has  arrived  at  the  same  conclusion  as  has  the 
United  States  Public  Health  and  Marine  Hospital  Service,  that  original 
research  is  a  function  of  the  public  health  administration.     No  amount  of 


250  HYGIENE 

enthusiasm  or  propagandism  will  take  the  place  of  research,  \\niile  the 
public  will  follow  a  medical  agitator  for  a  time,  any  agitation  not  based  upon 
well-ascertained  fact  will  soon  become  "  a  nine  days'  wonder,"  and  fall  by 
the  wayside.  I  find  it  very  difficult  to  impress  some  of  my  anti-tuberculosis 
friends  with  the  idea  that  it  is  not  well  to  go  faster  than  the  laboratory  can 
keep  up  with,  nor  to  proclaim  as  facts  those  things  not  definitely  determined 
by  research. 

In  the  chapter  upon  "  Army  and  Navy  Hygiene  "  the  opinion  is  expressed 
that  the  final  type  of  health  administration  will  probably  be  of  a  semi-military 
character,  and  that  such  organization  has  a  great  advantage  in  that  the  poli- 
tician cannot  spoil  it.  New  York  is  but  one  of  several  cities  in  which  this  ten- 
dency is  already  showing.  Probably  they  do  not  realize  it,  but  a  person 
coming  from  a  smaller  city  notes  it  at  once  and  just  as  he  does  of  the  police. 
My  opinion  may  not  weigh  much  in  the  matter,  but  I  favor  such  development 
as  likely  not  only  to  furnish  better  service  to  the  public,  but  also  to  promote 
harmony  between  the  health  administration  and  the  general  practitioner  of 
medicine.  When  a  local  physician  whose  activities  have  been  more  political 
than  medical  is  placed  in  charge  of  the  health  work,  and,  in  a  sense,  is  placed 
over  a  number  of  physicians  who  may  know  more  of  sanitation  than  he  does, 
the  result  is  seldom  satisfactory.  A  man  trained  in  the  work  and  wearing  a 
military  uniform  commands  respect  at  once. 

Not  as  a  matter  of  financial  data,  but  simply  as  an  impression,  I  am  in- 
clined to  the  belief  that  the  clerical  force  in  New  York  city  accomplishes 
more  than  is  the  case  in  most  health  bureaus.  Probably  the  clerical  work  is 
simplified,  but  it  impressed  me  that  vital  statistics  there  are  adequately  col- 
lected and  recorded  with  a  small  force.  This  is  a  matter  of  importance,  as  the 
expense  involved  is  preventing  many  of  the  states  from  undertaking  this 
work  as  it  should  be  done  for  proper  scientific  registration. 

The  day  has  gone,  I  hope  never  to  return,  when  a  doctor  may  be  a  mere 
palliator,  prescriber,  and  pathologist.  He  needs  to  be  a  sociologist,  a  sani- 
tarian, and  a  scientist.  Until  he  becomes  all  of  this,  he  will  not  take  his  full 
place  in  the  world.  The  same  applies  to  a  health  board.  The  board  we  are 
considering  realizes  this  fact.     Can  I  say  anything  better  of  its  work  ? 

A  last  word. —  It  may  not  be  amiss  to  say  in  ending  this  section,  that  it 
has  been  prepared  from  two  standpoints;  first,  that  of  the  general  practitioner 
rather  than  that  of  the  professional  sanitarian;  second,  from  a  77ational  point 
of  view  instead  of  that  natural  to  me  as  a  citizen  of  an  Inland  eastern  town. 
Therefore,  the  health  officer  should  not  let  me  tincture  his  ideas  with  anything 
contrary  to  the  regulations  he  is  under  oath  to  follow  in  his  own  state,  and  the 
general  practitioner  who  may  not  have  read  state  medicine  extensively  should 
not  think  this  brief  chapter  exhaustively  covers  the  subject.  However,  it 
does  not  hurt  the  health  officer  to  read  the  Ideas  of  a  private  practitioner,  and 
it  will  benefit  the  general  run  of  physicians  to  secure  copies  of  their  local  and 
state  regulations  and  study  them  carefully. 


RECEPTION   HOSPITAL,  DEPARTMENT  OF  HEALTH,   NEW  YORK  CITY 

SCARLET  FEVER  BUILDING,  DEPARTMENT  OF  HEALTH,  NEW  YORK  CITY 

ADMINISTRATION  BUILDING,  DEPARTMENT  OF  HEALTH,  NEW  YORK  CITY 


Chapter  XII 
ARMY  AND  NAVY  SANITATION  —  HYGIENE  OF  CAMPS 


Introductory  —  Organization  —  Recruits  —  Hygiene  in  peace  —  In  war  —  In  battle  — 
Camps  —  Water  supply  —  Rations  —  Disposal  of  excreta-housing  —  Transmissible  diseases  — 
Typhoid  fever  —  Malaria  —  Diarrhoeas  —  Bubonic  plague  —  Venereal  diseases  —  Other  in- 
fections —  Tropical    diseases  —  Clothing  —  Marches  —  The  canteen. 

Special  Naval  Regulations  —  To  enter  medical  service  of  —  Medical  school  of  — Duties 
of  medical  officers  —  Enlistment  —  Sanitary     regulations  —  Quarantine  — .Insanity  in  navy. 

Public  Health  and  Marine  Hospital  Service  —  A  general  survey  of  its  functions  and 
the  work  it  has  done  —  Other  camps  —  Contractors'  labor  camps  —  Camps  in  time  of  public 
disaster  —  The  lessons  the  general  practitioner  can  learn  from  the  army  and  navy. 


/NTRODUCTORr  —  Surgeon  Sheldon  G.  Evans,  of  the  United  States 
Navy,  has  well  said   {The  Military  Surgeon,  October,   1908):   "  Far  be 

it  from  me  to  detract  from  the  dignity  of  the  position  of  a  medical  officer 
in  any  honorable  service;  but  I  am  one  of  the  old  style  medical  men  who 
look  upon  the  title  of  doctor  of  medicine  as  the  highest  in  the  gift  of  any 
university  or  college,  and  upon  the  practice  of  medicine,  the  healing  of  the 
sick,  succoring  the  helpless,  and  relieving  the  sufferings  of  overburdened 
humanity  as  the  noblest  profession  under  God's  blue  canopy,  and  this  all 
ought  to  admit  as  the  first  and  most  important  duty  of  a  medical  man  in  any 
or  either  service.     To  be  a  doctor  first  and  a  medical  officer  afterwards." 

The  present  writer  views  the  matters  involved  in  this  chapter  from  the 
standpoint  of  the  general  practitioner  of  medicine.  While  not  an  army  or 
navy  man,  considerable  observation  of  army  camps  and  some  little  contact 
with  the  naval  establishment,  added  to  extensive  reading  of  books  and  jour- 
nals devoted  to  such  matters,  has  interested  me  in  the  problems  of  army  and 
navy  sanitation  sufficiently  to  have  formed  some  very  definite  opinions.  They 
are  given  for  what  they  are  worth. 

lam  well  aware  that  the  whole  problem  involves  a  specialty  thoroughly 
elaborated  by  many  men  and  many  governments,  and  yet  there  is  a  sufficient 
degree  of  unrest  noted  among  medical  officers  of  the  different  establishments 
to  indicate  that  the  general  reorganization  of  things  medical  and  surgical 
going  on  all  over  the  world  is  being  reflected  in  the  armies  and  navies  of  the 
world  as  well.  This  is  especially  the  case  since  the  war  between  Russia  and 
Japan  and  in  which  the  value  of  sanitation  was  strikingly  manifested. 

It  would  be  far  from  me  to  take  an  attitude  antagonistic  to  our  excellent 
military  organization  in  the  United  States,  and  yet  our  best  soldiers  realize 
that  the  American  temperament  is  such  as  to  allow  an  initiative  and  latitude 
to  our  soldiers  not  deemed  wise  by  the  older  organizations  in  Europe.  If  this 
is  true  of  the  officers  devoting  their  attention  to  field  work  and  tactics,  it  is 
equally  true  of  the  medical  officer.  The  past  few  years  have  shown  that 
medical  men  may  be  safely  given  command  in  civil  affairs  relating  to  the 


252  HYGIENE 

public  health.  City  sanitation  was  never  efficient  in  the  time  when  the  medi- 
cal health  officer  had  no  power  to  enforce  his  orders  except  by  tedious  appeal 
to  the  authorities  who  were  usually  entirely  ignorant  of  sanitary  necessities. 
If  there  was  one  especial  reason  why  sanitation  was  effective  in  the  Japanese 
army  it  was  because  the  medical  officer  of  a  certain  grade  had  the  same  power 
of  command  as  did  the  equivalent  officer  in  the  ranks. 

With  all  deference  to  West  Point  and  Annapolis,  the  academic  point  of 
view  and  tradition  have  no  place  in  modern  sanitation,  either  in  military  or  in 
civil  affairs.  When  we  take  into  consideration  that  the  history  of  armies 
makes  apparent  that  disease  kills  more  soldiers  than  do  bullets  and  weapons, 
sanitation  becomes  a  subject  of  at  least  equal  importance  to  tactics.  It  is 
fair  to  assume  that  the  medical  branch  of  any  service  is  one  of  the  most  im- 
portant of  its  varied  features,  and  is  manned  by  men  the  equal  in  training  of 
the  gentlemen  with  whom  they  come  into  contact. 

On  the  other  hand,  there  are  so  many  advantages  connected  with  mili- 
tary forms  of  administration  that  Europe  has  injected  a  certain  amount  of 
military  method  and  discipline  into  many  forms  of  public  service.  We  have 
an  illustration  in  Pennsylvania.  For  many  years  a  large  force  of  coal  and 
iron  police  were  kept  in  service  by  the  corporations  so  liable  to  suffer  destruc- 
tion of  property  by  riot  or  by  strike.  This  large  force  has  been  disbanded 
and  has  been  succeeded  by  state  constabulary.  About  two  hundred  of  these 
mounted  police  are  kept  constantly  in  the  field  and  are  probably  the  most 
effective  police  organization  in  the  United  States,  largely  because  they  are 
under  military  discipline,  and  in  constant  training.  In  the  chapter  upon 
state  boards  of  health,  I  have  taken  occasion  to  predict  the  ultimate  semi- 
military  organization  of  these  necessary  establishments.  We  are  cursed 
with  crooked  politics  in  our  states,  and  about  the  only  way  to  free  sanitation 
from  its  blighting  influence  is  to  ally  it  with  something  with  which  the  poli- 
tician cannot  deal.  If  my  view  be  correct,  military  ideals  and  ideas  are  a 
coming  horizon  for  the  sanitarian,  and  army  and  navy  sanitation  is  a  study 
worthy  the  attention  of  every  doctor. 

In  our  present  consideration,  it  is  impossible  to  give  any  adequate  con- 
ception of  army  and  navy  methods  by  merely  repeating  the  sanitary  regula- 
tions issued  by  the  surgeons  general.  We  must  be  permitted  to  cover  a 
slightly  wider  field.  One  is  at  once  confronted  by  the  army  claim  that  they 
have  the  most  difficult  task  because  of  taking  conditions  as  they  find  them 
instead  of  living  upon  a  well-constructed  vessel.  On  the  other  hand,  the  navy 
man  says  his  work  is  done  in  a  community  vastly  overcrowded,  and  that  to 
keep  the  occupants  of  a  ship  from  being  swept  off  by  epidemic  is  more  diffi- 
cult than  upon  land  where  camps  can  be  spread  out  or  moved.  I  have  taken 
occasion  to  carefully  study  the  instructions  for  medical  officers  issued  by  both 
branches  of  the  service,  and  shall  give  more  attention  to  the  navy  literature 
because  it  covers  a  somewhat  wider  field  and  embraces  most  of  what  is  given 
in  the  army  as  well  as  other  conditions  with  which  the  army  does  not  have  to 
deal.  As  to  which  branch  of  the  service  presents  the  greatest  of  difficulty  in 
sanitation,  I  do  not  pretend  to  know. 

This  book  being  written  for  civil  rather  than  for  military  readers,  a  host 


ARMY  AND  NAVY  SANITATION  253 

of  administrative  matters  of  military  interest  will  be  wholly  omitted;  hence, 
the  writer  deliberately  lays  himself  open  to  the  charge,  just  from  the  military 
point  of  view,  of  omitting  one  of  the  most  important  branches  of  the  subject. 
However,  there  are  some  things  in  military  red,  white,  and  blue  tape  that  do 
not  seem  so  impressive  to  the  average  citizen  as  they  do  to  the  military  officer, 
and  I  will  take  occasion  to  define,  under  the  next  heading,  some  adminis- 
trative heresy  that  I  see  cropping  out  of  the  pages  of  The  Military  Surgeon  at 
intervals  and  that  seems  to  be  "  sapping  the  faith  "  of  some  of  the  brightest 
men  in  the  service.  The  chapter  will  end  with  a  discussion  of  the  Public 
Health  and  Marine  Hospital  Service. 

Organization. —  There  is  a  chapter  in  this  book  devoted  to  a  discussion  of 
a  proposed  national  department  of  health.     The  military  branch  of  the  gov- 
ernment prefers  that  such  a  department  be  upon  a  military  basis.     With  this 
suggestion  the  present  writer  agrees.     As  things  are,  the  army,  the    navy, 
and  the  Public  Health  and  Marine  Hospital  Service  have  each  their  medical 
organization.     They  each  have  hospitals  sometimes  almost  side  by  side  (as 
in  Boston),  their  equipment  differs,  whereas  there  is  little  adequate   reason 
why  it  should,  there  is  a  duplication  of  recruiting  stations  and  many  store- 
houses and  administrative  buildings,  some  branches  have  too  many  medical 
men,  while  some  other  branch  has  too  few  and  they  do  not  interchange, 
a  vast  deal  of  clerical  work  is  done  under  the  three  organizations  that  a 
"  trust  "  would  eliminate  in  short  order;  there  are  separate  medical  schools 
conducted  that  would  be  better  combined  into  one;  there  is  a  vast  deal  of 
professional  dry  rot  resulting  from  a  medical  man  being  assigned  to  a  post 
where  he  has  Httle  to  do  but  render  routine  reports,  and  this  cannot   be 
helped  under  the  present  inflexible   system,  and  the  divided  system  does  not 
permit  of  the  medical  department  having  its  own  transportation  and  commis- 
sary.   Such  are  the  reasons  advanced  in  favor  of  a  union  of  the  different  divi- 
sions of  the  government  medical  service.   I  have  talked  with  the  men  who  favor 
the  present  organization  and  they  strenuously  oppose  any  such  changes  as  are 
suggested,  raising  a  host  of  small  objections  that  to  my  mere  civilian  mind 
did  not  appear  very  weighty.     However,  unless  a  department  of  health  were 
established  along  military  lines,  or  maritime  quarantine  be  placed  exclusively 
in  federal  hands  (which  is  not  apt  to  be  done  for  a  long  time),  uniting  the  three 
branches  of  the  medical  service  would  result  in  a  considerable  number  of 
medical  officers  losing  their  commissions.     Establishing  a  federal  department 
would  obviate  this  loss  to  many  very  excellent  physicians. 

Recruits. —  This  matter  will  be  sufficiently  discussed  under  the  heading 
"  Enlistment  "  when  we  discuss  the  navy  regulations. 

Hygiene  in  -peace. —  With  the  regular  army,  this  is  upon  a  very  satisfac- 
tory basis,  the  troops  being  seasoned  and  the  ration  regular.  The  commands 
are  not  very  large,  and  the  camps  are  changed  sufficiently  often  to  prevent 
trouble.  Troops  in  garrison  are  little  of  a  sanitary  problem  in  these  days, 
except  when  the  garrison  is  too  near  to  certain  diversions  for  which  soldiers 
have  a  weakness.  National  guards  of  the  various  states  go  into  practice  en- 
campment annually  and  some  degree  of  sickness  occurs  among  the  men 
because  they  are  not  inured  to  camp  life.     The  sanitary  problem  in  time  of 


254  HYGIENE 

peace  is  so  similar  to  that  of  times  of  war  that  separate  discussion  is  hardly 
demanded,  except  to  say  that  the  reports  are  of  such  a  character  as  to  indicate 
the  necessity  for  care  in  preventing  the  spread  of  venereal  diseases. 

Hygiene  in  war. —  This  subject  will  be  limited  to  a  discussion  of  hygiene 
in  the  field,  and  need  not  take  up  barracks,  the  hygiene  of  which  is  largely 
that  of  a  hotel  or  large  lodging  house,  only  administered  in  a  military  manner. 
In  the  field  routine  reports  and  records  should  be  simplified,  except  those 
relating  to  the  injuries  and  illnesses  occurring.  It  is  the  duty  of  the  medical 
officer  to  make  the  command  the  best  fighting  unit  he  can,  and  he  must 
do  this  by  preserving  the  health  of  each  and  every  individual.  He  should  not 
give  all  of  his  attention  to  the  large  features;  he  must  look  after  the  individual 
as  well.  It  is  very  necessary  that  the  general  stafFand  the  medical  department 
be  as  one  and  that  medical  supplies  be  abundant  and  the  stores  of  such  a  char- 
acter as  to  restore  the  sick  and  wounded  to  the  lines  as  soon  as  is  consistent 
with  good  work  and  humanitarianism.  In  modern  war,  the  number  of 
wounded  is  often  one  fourth  of  the  whole  command,  but  the  number  of  serious 
wounds  is  diminishing,  owing  to  long-distance  fighting. 

Modern  warfare  has  accentuated  the  benefit  to  be  deiived  from  the  use 
of  first  aid  dressings  supplied  to  the  soldiers  themselves,  and  it  is  a  matter 
of  hygiene  in  that  it  reduces  the  number  of  septic  wounds.  Field  organiza- 
tion is  a  matter  of  great  importance,  and  its  discussion  would  involve  so  much 
space  that  I  would  recommend  interested  physicians  to  write  to  the  surgeon 
general  for  a  copyof  the  "Medical  Department  Manual."  He  will  not  be  likely 
to  supply  copies  at  random,  however.  This  really  admirable  volume  gives  a 
very  clear  idea  of  what  may  be  expected  of  the  medical  officer  under  all  con- 
ditions. I  am  very  much  inclined  to  indulge  the  personal  view  that  the  medi- 
cal officer  is  justified  in  specializing.  Sanitation  is  of  constant  use,  but  sur- 
gery of  only  occasional  need.  Even  in  time  of  war  many  surgeons  get  really 
little  experience  in  surgery.  It  seems  to  me  that  the  major  surgery  could 
usually  be  well  left  to  the  surgeons  of  special  experience  and  training.  The 
diseases  with  which  the  military  surgeon  has  to  do  will  be  discussed  pre- 
sently. Very  fortunately,  hard  campaigning  and  fighting  do  not  induce  com- 
municable diseases.  Col.  Valery  Havard,  Assistant  Surgeon  General,  U.  S.  A., 
is  reported  to  have  said  in  an  address : 

Until  recent  years  all  sanitary  work  in  our  camps  was  done  under  the  immediate 
supervision  of  the  quartermaster's  department.  Medical  officers  were  simply  per- 
mitted to  make  recommendations  which  were  more  or  less  heeded.  There  was,  there- 
fore, a  divided  responsibility  which  bred  indifference  and  prevented  the  attainment 
of  the  best  results,  ll  has,  at  last,  been  realized  that  military  hygiene  is  specialized 
knowledge  and  that  medical  officers  are  best  fitted  to  direct  and  supervise  its  applica- 
tion. Hence  came  the  sanitary  organization  of  some  of  our  latest  camps,  where  the 
whole  business  of  sanitation,  conception,  and  execution  was  entrusted  to  the  medical 
department,  and,  as  we  know,  with  the  happiest  results.  The  quartermaster's  depart- 
ment was  simply  called  upon  to  furnish  the  material  and  hire  the  necessary  laborers. 
In  my  opinion,  it  would  be  a  still  further  advance  if  the  medical  department  controlled 
all  the  sanitary  material  and  personnel.  This  control  would  be  for  the  best  interest  of 
the  service,  and  we  may  confidently  soon  expect  to  obtain  it. 


ARMY  AND  NAVY  SANITATION  255 

Thus  we  see  how  the  medical  officer  must  become  a  practical  adminis- 
trator.    It  takes  a  really  big  man  to  fill  the  bill  acceptably. 

In  addition  to  this,  he  must  be  prepared  to  instruct  the  men  in  sanitation. 
Another  duty  in  wartime  is  for  him  to  instruct  the  medical  officers  of  the  state 
militia  and  the  volunteers  always  raised  in  time  of  war.  The  appointment  of 
these  men  is  upon  altogether  too  loose  a  basis.  With  all  deference  to  the 
general  practitioner  of  medicine,  he  is  seldom  prepared  to  attempt  the  sani- 
tation of  a  camp.  The  contract  surgeons  and  the  medical  officers  of  state 
troops  may  be  most  excellent  physicians  and  surgeons,  but  that  does  not 
make  them  capable  sanitarians  by  any  manner  of  means.  I  enjoyed  much 
opportunity  to  observe  how  the  mixed  system  worked  during  the  Spanish- 
American  war.  There  was  fault  upon  both  sides.  It  is  not  necessary  here 
to  go  into  details,  but  the  fact  is  that  certain  regulations  that  failed  to  appeal 
to  the  civilian  doctors  were  necessary  for  the  service.  The  kits  of  surgical 
instruments  and  the  chests  of  drugs  cannot  be  varied  to  suit  the  individual 
ideas  of  all.  The  regular  army  medical  officer  attains  a  specialized  knowledge 
of  the  drugs  regularly  supplied,  and  gets  along  with  them  very  well.  Not  so 
some  of  the  physicians  suddenly  called  upon  to  serve  in  an  army  camp.  But 
some  of  the  "  regulars  "  can  shake  up  a  chest  in  the  dark  and  tell  just  what  is 
there  and  the  "  vagaries  "  of  some  of  the  "  civilian  "  doctors  got  upon  their 
nerves.  I  remember  a  rather  pompous  medical  officer,  as  inefficient  as  he  was 
pompous,  throw  several  kinds  of  patent  elliptical  fits  over  the  fact  that  a  really 
distinguished  civilian  doctor  in  the  command  had  in  his  chest  a  few  drugs 
not  upon  the  list.  A  little  fraternal  co-operation  would  have  avoided  much 
friction. 

It  would  be  an  excellent  thing  for  all  of  the  physicians  of  military  age  to 
familiarize  themselves  with  the  general  principles  of  military  and  naval 
hygiene.  There  is  no  lack  of  text-books  and  "  The  Military  Surgeon," 
edited  in  Washington,  D.  C,  will  afford  a  sort  of  correspondence  course  in 
the  subject. 

And  that  is  not  all  that  is  necessary.  Every  state  owes  it  to  its  citizens 
who  may  be  called  to  the  colors,  that  a  body  of  medical  officers  be  trained, 
not  only  in  the  theory  and  details  of  military  hygiene,  but  in  the  administra- 
tion of  the  matter.  Things  were  thoroughly  bad  in  the  Spanish-American 
war,  and  we  may  just  as  well  admit  the  fact.  I  saw  enough  myself  to  con- 
vince me  that  the  best  of  family  doctors  positively  is  no/ worth  while  as  a  mili- 
tary sanitarian.  Just  what  should  be  done  I  confess  I  do  not  know,  but  am 
inclined  to  believe  that  the  state  boards  of  health  and  the  state  militia  should 
get  together  and  devise  a  way  to  put  In  training  certain  physicians  in  the 
several  communities,  in  order  to  meet  the  possible  emergencies  of  the  situa- 
tion confronting  the  nation  in  time  of  war.  I  am  aware  that  there  are  cer- 
tain organizations  endeavoring  to  train  men  to  meet  emergencies  in  time  of 
disaster,  but  the  results  are  hard  to  judge.  My  view  is  that  every  state 
should  train  the  men  selected  strictly  along  federal  army  methods,  so  as  to 
have  an  absolute  uniformity.  The  medical  officers  of  the  state  militia  get  a 
slight  training,  but  they  are  seldom  selected  with  any  regard  to  their  efficiency 
as  sanitarians.     Some  day  this  nation  will  pay  an  awful  price  for  its  neglect  of 


256  HYGIENE 

military  matters,  and  especially  for  its  neglect  of  military  training  for  its  medi- 
cal officers.  There  is  a  lot  of  talk  about  the  sovereign  rights  of  the  states, 
but  very  little  about  the  sovereign  duties.  All  manner  of  sanitary  matters 
are  being  taken  up  by  the  states,  and  there  is  a  great  opportunity  offered,  in 
co-operation  v^ith  a  semi-military  federal  department  of  health,  of  making 
the  medical  officers  in  the  state  organizations  men  of  similar  training  and 
resource.  In  my  view  of  the  matter,  that  is  w^hat  we  will  have  to  come  to 
ultimately,  and  it  will  result  in  better  service,  more  economical  administra- 
tion, a  very  badly  needed  separation  from  politics,  a  uniformity  over  the 
country,  and  sanitar}^  preparedness  in  time  of  war. 

Hygiene  in  battle. —  Probably  one  who  has  never  seen  a  real  battle  should 
say  nothing  under  this  heading.  But  I  have  talked  with  those  who  have  seen 
much  fighting  and  find  it  difficult  to  induce  them  to  write  anything  except 
for  miUtary  publications.  What  they  have  told  me  leads  me  to  the  belief 
that  hygiene  in  battle  is  one  of  the  things  sanitarians  may  dream  over  but 
never  attain.  From  my  reading,  I  find  that  the  most  effective  sanitary  pre- 
caution our  government  has  undertaken  for  use  upon  the  firing  line  is  the 
supplying  of  first  aid  packets  to  the  soldier.  An  examination  of  this  packet 
shows  it  to  be  most  admirable,  as  it  is  contained  in  a  metal  box  encased  in  a 
canvas  cover  and  fastened  to  the  cartridge  belt.  Doubtless  it  has  saved  many 
lives  and  the  men  need  not  be  hastened  to  the  rear  so  fast.  Another  precau- 
tion is  to  see  that  their  water  supply  carried  into  battle  is  good.  The  Japan- 
ese navy  always  have  their  men  bathe  and  put  on  clean  clothing  before  going 
into  action.  This  would  be  harder  to  do  with  land  foices.  Naval  writers 
tell  of  the  difficult  position  of  the  medical  department  during  action.  Such 
fights  are  very  apt  to  be  one-sided  affairs.  The  fortunate  shot  or  the  heaviest 
gun  or  the  well-placed  mine  or  torpedo  will  render  a  vessel  impossible,  from 
the  surgical  status,  in  short  order,  while  the  winning  vessel  may  hardly  be 
hurt  and  things  go  on  like  they  do  during  target  practice.  Persons  who  have 
seen  a  vessel  with  a  short  complement  of  men,  but  partially  supplied  with 
stores  and  coal,  and  most  of  the  machinery  covered,  have  little  idea  what  a 
crowded  place  a  vessel  is  when  stripped  for  action.  The  difficulties  are 
immense. 

Camps 

It  is  the  camp  that  tests  the  efficiency  of  the  sanitary  service.  Well  do  I 
remember  my  childish  sorrow  when  my  maimed  and  sick  relatives  from  the 
war  between  the  states  would  tell  us  of  their  hardships  in  the  camps.  Sani- 
tation was  a  largely  untried  experiment  in  those  days,  and  the  wonder  is  that 
things  were  no  worse.  Any  one  who  looks  over  the  medical  and  surgical 
history  of  that  war  will  give  large  honors  to  the  splendid  men  who  served  in 
its  hospitals  and  upon  the  field.  There  are  even  creditable  records  of  the 
sanitary  efforts  made  and  the  hospitals  and  hospital  vessels  were  an  honor  to 
their  time.  But  when  one  visits  the  G.  A.  R.  camps  of  to-day  and  notes 
the  comments  of  the  old  soldiers  upon  the  modern  appliances  they  there 
see,  one  finds  that  they  place  more  reliance  upon  hardy  manhood  than  they 
do  upon  modern  invention.     Down  in  the  Canal  Zone  certain  negro  laborers 


n  2 

o     o 


C 


^     > 

^    5 


3     n 


ARMY  AND  NAVY  SANITATION  257 

were  housed  in  well-ventilated  and  properly  screened  buildings,  and  they  had 
a  large  mortality  record  because  they  were  used  to  sleeping  in  huts  reeking 
with  filth  and  dead  air.  They  contracted  colds  and  pneumonia  in  good 
buildings.  It  is  much  the  same  when  you  take  an  Indian  from  his  tepee  or  an 
Eskimo  from  his  hut.  The  sanitary  administration  of  Cuba  is  much  con- 
cerned over  yellow  fever,  because  the  immune  is  becoming  more  rare,  and  the 
population  is  more  susceptible  to  the  infection  from  year  to  year.  Our  own 
American  young  men  seem  to  contract  typhoid  too  readily.  All  this  suggests 
a  weak  spot  in  sanitation  vastly  accentuated  in  the  army  camp. 

One  of  the  best  things  that  can  happen  to  a  camp,  from  the  sanitary  point 
of  view,  is  to  have  the  enemy  near.  This  makes  it  necessary  to  scatter  the 
brigades  and  to  present  an  extended  front.  Such  camp  formation  is  to  be 
commended  at  all  times. 

Water  supply. —  I  have  seen  a  regular  piped  supply  laid  through  military 
camps.  Usually  this  is  impossible,  but  the  expense  may  be  fully  justified  in 
many  instances.  There  need  be  no  extended  discussion  of  this  matter  here, 
since  water  supply  is  fully  covered  in  other  portions  of  this  book.  But  the 
especial  features  of  a  camp  supply  will  be  very  briefly  outlined.  The  medical 
officer  should  always  examine  all  new  sources  of  supply,  but  it  is  not  to  be 
expected  that  he  can  make  a  good  bacteriological  examination  in  the  field. 
Condemned  water  should  never  be  used,  but  it  takes  severe  penalties  some- 
times to  prevent  the  soldier  from  taking  the  risk.  Sterilization  by  boiling  is 
the  main  reliance  in  the  preparation  of  water  for  the  soldier.  This  matter 
became  really  automatic  in  the  Japanese  army,  since  the  universal  drink  was 
tea.  Sterilizing  large  quantities  of  water  presents  many  difficulties  in  the 
field,  but  they  are  not  insurmountable.  The  Forbes  sterilizer  is  largely  in 
use  in  our  army,  and  the  latest  pattern  supplies  sterilized  cold  water.  If 
water  be  raised  to  176  degrees  F.  and  be  maintained  there  for  a  short  time, 
the  pathogenic  bacteria  liable  to  contaminate  water  are  killed  and  the  water 
does  not  taste  so  flat  as  does  boiled  water  and  less  fuel  is  required  in  the  pro- 
cess. Apparatus  requiring  special  fuel  is  not  suited  for  field  use.  Where  ten 
gallons  of  rhineral  oil  can  be  procured  every  day,  water  can  be  sterilized  for 
three  thousand  troops  in  an  oil-operated  apparatus.  There  are  many  practical 
difficulties  in  transporting  and  operating  regularly  any  sort  of  sterilizer. 
There  are  many  filters  in  use  by  various  armies,  the  Darnell  outfit  being 
the  one  most  in  use  in  our  army.  For  a  full  description  of  this  filter  see  The 
Military  Surgeon,  for  April,  1908.  This  apparatus,  packed,  weighs  three 
hundred  and  ninety  pounds,  has  a  maximum  capacity  of  four  hundred  gal- 
lons of  filtered  water  per  hour,  uses  alum  and  soda  as  precipitants,  imparts 
little  if  any  taste  to  the  water,  makes  the  water  perfectly  clear,  and  removes 
as  high  as  ninety-nine  per  cent  of  all  bacteria,  in  actual  service. 

Water  may  be  purified  by  chemicals,  chlorine,  bromine,  hydrochloric 
acid,  and  potassium  permanganate  being  used  at  various  times.  All  of  these 
methods  are  academic  and  are  spoken  of  here  merely  because  they  are  still 
found  in  books  upon  military  hygiene.  In  practical  use  they  are  far  from 
satisfactory.  The  precipitation  process  using  alum  and  other  chemicals  is 
discussed  in  Chapter  XXII. 


258  HYGIENE 

Considerable  attention  has  been  called  to  methods  of  water  purification 
by  ozone.  Superior  results  have  been  claimed  for  the  method  under  certain 
circumstances.  Some  years  ago  I  devised  an  apparatus  designed  to  produce 
quantities  of  ozone  and  conducted  some  experiments  vi^ith  it.  At  first  I  felt 
some  enthusiasm  over  the  matter,  but  finally  found  that  the  reactions  pro- 
duced v^ith  ozone  varied  so  remarkably  under  varying  conditions  not  appar- 
ently according  with  the  range  of  practicability  that  I  was  compelled  to  admit 
that  ozone  is  not  an  agent  upon  which  we  can  rely  and  that  its  real  uses  are 
very  limited,  except  when  made  upon  a  large  scale.  Unless  some  means  are 
found  to  produce  ozone  uniformly  and  of  uniform  characteristics,  I  do  not 
believe  it  will  be  a  real  factor  in  the  purification  of  water  for  camps.  Com- 
mercial ozone  plants  are  practical.     (See  Chapter  XXII.) 

Rations. —  A  large  amount  of  study  has  been  given  to  the  army  ration 
and  it  is  upon  a  scientific  basis.  But  as  this  is  not  a  book  upon  dietetics,  there 
is  no  occasion  to  enter  upon  a  discussion  of  the  matter  in  this  connection. 
The  hygiene  is  partly  covered  in  the  chapter  upon  "  Pure  Food  and  Drugs." 
But  aside  from  that  and  matters  of  quality  carefully  scanned  by  the  govern- 
ment, it  is  important  to  watch  the  cook.  I  have  personally  seen  military 
camps  where  I  would  be  afraid  to  eat  a  meal.  They  were  not  camps  of  regu- 
lar soldiers.  The  commissary  of  every  command  must  be  under  the  constant 
scrutiny  of  a  capable  officer.  There  is  very  little  occasion  for  complaint 
because  of  the  food  itself  in  any  kind  of  command  to-day,  but  there  may  be 
carelessness  in  any  of  them  unless  under  constant  inspection.  Keeping  food 
clean,  away  from  dust,  cool,  dry,  free  of  insects  and  worms,  careful  cooking, 
clean  serving,  proper  disposal  of  garbage,  and  above  all  absolutely  screening 
from  flies,  are  all  very  necessary  in  the  camp  and  upon  the  march.  The  sub- 
ject is  too  large  to  be  entered  into  at  length  here  and  special  books  should  be 
consulted  by  interested  persons.  The  army  regulations  are  adequate  and 
could  well  be  followed  by  camps  not  connected  with  the  regular  army. 

As  to  flies,  permit  me  to  incorporate  here  for  the  benefit  of  persons  who 
may  be  compelled  to  live  in  a  camp,  a  circular  issued  by  the  Chicago  Depart- 
ment of  Health  and  circulated  principally  among  house  dwellers.  It  applies 
with  peculiar  force  to  camps  in  some  of  its  specifications: 

Don't  allow  flies  in  your  house. 

Don't  permit  them  near  your  food  —  especially  milk. 

Don't  buy  foodstufi^s  where  flies  are  tolerated. 

Don't  eat  where  flies  have  access  to  the  food. 

Flies  are  the  most  dangerous  insects  known  to  man. 

Flies  are  the  filthiest  of  all  vermin.  They  are  born  in  filth,  live  on  filth,  and  carry 
filth  around  with  them.     They  are  maggots  before  they  are  flies. 

Flies  are  known  to  be  carriers  of  millions  of  death-dealing  disease  germs.  They 
leave  some  of  these  germs  wherever  they  alight. 

Flies  may  infect  the  food  you  eat.  They  come  to  your  kitchen  or  to  your  dining 
table,  fresh  from  the  privy  vault,  from  the  garbage  box,  from  the  manure  pile,  from  the 
cuspidor,  from  decaying  animal  or  vegetable  matter,  or  from  the  contagious  sickroom 
with  this  sort  of  filth  on  their  feet  and  in  their  bodies,  and  they  deposit  it  on  your  food, 
and  you  do  swallow  filth  from  privy  vaults,  etc.,  if  you  eat  food  that  has  come  in  contact 
with  flies. 


ARMY  AND  NAVY  SANITATION  259 

Flies  may  infect  you  with  tuberculosis,  typhoid  fever,  scarlet  fever,  diphtheria, 
and  other  infectious  diseases.  They  have  the  habit  of  feasting  on  tuberculosis  sputum 
and  other  discharges  of  those  sick  with  these  diseases,  and  then  go  direct  to  your  food, 
to  your  drink,  to  the  lips  of  your  sleeping  child,  or  perhaps  to  a  small  open  wound  on 
your  hands  or  face.  When  germs  are  deposited  in  milk  they  multiply  very  fast; 
therefore,  milk  should  never  be  exposed  to  flies. 

What  to  do  to  Get  Rid  of  Flies 

Screen  your  windows  and  doors.  Do  it  early  before  flytime  and  keep  screens  up 
until  snow  falls. 

Screen  all  food,  especially  milk.  Do  not  eat  food  that  has  been  in  contact  with 
flies. 

Screen  the  baby's  bed  and  keep  flies  away  from  the  baby's  bottle,  the  baby's 
food,  and  the  baby's  "  comforter." 

Keep  flies  away  from  the  sick,  especially  those  ill  with  typhoid  fever,  scarlet  fever, 
diphtheria,  and  tuberculosis.  Screen  the  patient's  bed.  Kill  every  fly  that  enters  the 
sickroom.     Immediately  disinfect  and  dispose  of  all  discharges. 

Catch  the  flies  as  fast  as  they  appear.  Use  liquid  poisons,  sticky  fly  papers,  and 
traps. 

Place  either  of  these  fly  poisons  in  shallow  dishes  throughout  the  house:  (a)  Two 
teaspoonfuls  of  formaldehyde  to  a  pint  of  water,  or  (b)  One  dram  of  bichromate  of 
potash  dissolved  in  two  ounces  of  water,  sweetened  with  plenty  of  sugar. 

To  quickly  clear  rooms  of  flies,  burn  pyrethrum  powder  or  blow  powdered  black 
flag  into  the  air  of  the  room  with  a  powder  blower.  This  causes  flies  to  fall  to  the 
floor  in  stunned  condition.     They  must  then  be  gathered  up  and  destroyed. 

Eliminate  the  Breeding  Places  of  Flies 

Sprinkle  chloride  of  lime  or  kerosene  over  contents  of  privy  vaults  and  garbage 
boxes.  Keep  garbage  receptacles  tightly  covered,  clean  the  cans  every  day,  the  boxes 
every  week.     Keep  the  ground  around  garbage  boxes  clean. 

I  Sprinkle  chloride  of  lime  over  manure  piles,  old  paper,  old  straw,  and  other  refuse 
of  like  nature.  Keep  manure  in  screened  pit  or  vault  if  possible.  Manure  should  be 
removed  at  least  every  week. 

Pour  kerosene  into  the  drains.  Keep  sewerage  system  in  good  order,  repair  all 
leaks  immediately. 

Clean  cuspidors  every  day.  Keep  five  per  cent  solution  of  carbolic  acid  in  them 
all  the  time.  Get  rid  of  sawdust  boxes  used  as  cuspidors  —  destroy  them  —  they're 
insanitary. 

Don't  allow  dirt  to  accumulate  in  corners,  behind  doors,  back  of  radiators,  under 
stoves,  etc. 

Allow  no  decaying  matter  of  any  sort  to  accumulate  on  or  near  your  premises. 

Flies  in  the  home  indicate  a  careless  housekeeper.  Remember:  No  dirt  —  no 
flies. 

If  there  is  a  nuisance  in  the  neighborhood  notify  the  department  of  health,  city 
of  Chicago. 

It  is  cheap  to  condemn  and  destroy  all  doubtful  food  in  the  camp  and  to 
keep  a  supervision  over  food  sold  to  soldiers  by  merchants  and  restaurants 
contiguous  to  the  camp. 

Disposal  of  excreta. —  Pit  latrines  will  do  for  camps  of  a  few  days,  but 


260  HYGIENE 

they  must  be  so  constructed  as  to  exclude  flies  absolutely,  the  dejecta  must  be 
so  placed  as  to  be  readily  sterilized  without  removal,  and  soiled  parts  must 
not  be  too  valuable  to  burn.  The  best  device  for  brief  use  of  which  I  have 
knowledge  was  invented  by  Capt.  F.  A.  Herrick,  of  the  Ohio  National 
Guard.  Circular  holes  were  sunk  by  means  of  post  hole  augers  and  widened 
at  the  bottom  with  bars  or  other  devices.  They  were  sunk  upon  hillsides  and 
in  light  soil,  so  they  would  not  fill  with  water.  Galvanized  iron  cylinders  were 
fitted  into  these  holes  and  over  them  were  erected  metal  bowls  and  wooden 
seats  with  covers  automatically  closing.  Cheap  disinfectant  solutions  were 
siphoned  into  the  latrine  at  frequent  inten-^als.  Once  each  day  the  holes  were 
burned  out  with  paper  saturated  in  coal  oil.  When  breaking  camp,  lime  is 
thrown  in  and  the  holes  filled.  In  camps  used  for  long  periods,  the  McCall 
incinerator  is  almost  ideal.  It  is  most  too  elaborate  to  fully  describe  without 
diagrams,  but  can  be  seen  in  so  many  camps  of  United  States  troops  or  at  the 
factory  at  Huntington,  Tenn.,  that  interested  persons  can  readily  become 
familiar  with  its  workings.  Private  parties  can  procure  them  of  the  factory. 
In  many  camps  the  men  are  required  to  wash  their  hands  in  an  antiseptic 
solution  when  leaving  the  latrine  or  incinerator.  In  view  of  the  fact  that  urine 
may  carry  typhoid  bacilli,  care  must  be  exercised  to  prevent  urination,  ex- 
cept at  the  latrine.  Garbage  may  be  buried,  but  the  safest  and  best  way  is  to 
burn  it  at  once.  An  experienced  camp  cook  can  burn  so  much  of  it  that  it 
is  little  of  a  separate  problem. 

Housing  can  best  be  studied  from  the  regulations  and  upon  the  field. 
So  many  kinds  of  construction  are  used  in  the  army  and  so  many  forms  of 
tents  are  issued  that  our  present  space  precludes  a  study  of  the  matter.  I 
could  not  attempt  to  give  an  adequate  idea  of  the  subject  in  the  few  pages  at 
command.     See  special  works. 

Transmissible  diseases. —  These  are  the  same  in  military  as  in  civil 
life  and  the  treatment  calls  for  no  special  comment  here,  except  to  say  that 
the  military  physician  is  largely  limited  to  the  supply  table  in  the  selection  of 
his  drugs.  This  supply  table  has  been  much  called  in  question  by  contract 
physicians  who  feel  that  the  patient  needs  what  he  has  been  accustomed  to 
use.  There  is  truth  upon  both  sides,  but  the  field  difficulties  are  so  great 
that  one  should  not  criticise  the  medical  service  of  the  United  States  without 
seeing  for  himself  the  difficulties  of  the  situation.  As  a  matter  of  fact,  the 
mortality  records  of  the  army  and  navy  do  not  make  it  appear  that  the  welfare 
of  the  sick  soldiers  and  sailors  is  being  jeopardized  by  a  limited  drug  list. 
Upon  requisition,  properly  vised,  a  medical  officer  can  usually  get  most  any 
drug  he  may  need.  I  have  at  my  hand  "  Hygienic  Laboratory  Bulletin, 
No.  49,"  being  a  "  Digest  of  Comments  on  the  Pharmacopoeia  of  the  United 
States  of  America,"  and  issued  by  the  Government  Printing  Office  in  1909. 
It  is  an  answer  to  the  medical  critics  of  the  senice,  and  shows  conclusively 
that  the  service  is  keeping  abreast  of  therapeutic  advance. 

The  present  writer  is  inclined  toward  school  liberality  and  very  frankly 
uses  and  advocates  certain  drugs  of  eclectic  and  homoeopathic  origin,  yet  he 
cannot  see  how  a  government  can  recognize  three  pharmacopoeias,  and,  until 
the  schools  unite  in  pharmaceutical  matters,  there  is  no  hope  of  the  army  and 


ARMY  AND  NAVY  SANITATION  261 

navy  using  any  but  defined  preparations.  I  can  in  private  practice  do  so, 
but  would  not  think  of  attempting  it  in  my  hospital  service,  as  matters  would 
be  sadly  mixed  in  short  order.  Therefore,  were  I  in  the  medical  service  of 
the  army,  I  would  not  think  of  making  any  experiments.  A  short  experience 
substituting  in  the  Indian  service  some  years  ago  made  it  very  plain  to  me 
that  a  supply  table  is  very  necessary.  Furthermore,  observation  has  con- 
vinced me  that  the  men  in  the  medical  service  know  their  business. 

Typhoid  fever  has  a  very  high  mortality  rate  in  the  field  and  every  effort 
is  made  to  prevent  it.  From  my  observation  of  this  disease  in  camp  I  believe 
that  the  appearance  of  the  disease  therein  should  spell  marching  orders  within 
forty-eight  hours.  If  it  occurs  in  a  national  guard  camp  of  short  duration, 
the  camp  site  better  be  changed  the  next  year.  Malaria  is  well  controlled, 
now  that  we  know  how  it  is  disseminated,  and  there  is  comparatively  little  of  a 
problem  presented  to  the  medical  officer  practically  familiar  with  mosquito 
extermination.  Cases  may  well  be  transferred  to  base  hospitals.  Diar- 
rhoeas are  usually  preventable,  but  must  be  carefully  differentiated  from 
typhoid.  The  bacillus  coli  communis  is  responsible  for  many  cases,  and  the 
remedy  is  obvious.  Bubonic  plague  is  prevented  by  methods  described  for 
the  extermination  of  rats  in  the  chapter  upon  Slums  and  Town  Nuisances, 
and  need  not  be  repeated  here.  Venereal  diseases  are  common  in  all  armies 
and  navies.  The  navy  of  japan  admits  that  27.75  per  cent  of  all  admissions 
are  for  venereal  diseases,  and  some  persons  say  that  England  and  the  United 
States  show  even  a  worse  record.  I  have  read  a  large  amount  of  learned 
matter  as  to  how  to  suppress  venereal  diseases  in  the  army  and  navy,  but 
have  found  few  real  suggestions.  Any  one  who  visits  ports  and  keeps  his 
eyes  open  will  see  just  why.  Camps  are  bad  or  fair  in  this  regard,  according 
to  the  degree  of  latitude  allowed  by  the  officers.  Certain  things  are  so  deeply 
ingrained  in  human  nature  that  even  military  officers  are  inclined  to  wink  at 
them.  Perhaps  sometime  there  will  be  a  different  sentiment  among  soldiers 
and  sailors,  and  something  can  be  done  to  prevent  venereal  abuses.  That 
time  has  not  yet  come.  That  soldiers  and  sailors,  or  in  fact  any  class  of 
segregated  men,  will  ever  accord  with  the  point  of  view  of  the  "  purists  "  as 
to  the  "  amiable  vices  "  is  very  improbable.  Certainly  most  of  us  think  men 
should,  but  the  fact  is  they  never  did  accord  with  this  view.  See  the  chapter 
upon  Places  of  Amusement  and  Dissipation. 

Other  infections  are  of  importance  among  soldiers  and  sailors.  Measles 
has  been  a  serious  m.enace  in  camps  and  surgical  erysipelas  was  formerly  a 
serious  matter.     Mumps  sometimes  assumes  a  threatening  aspect  in  camps. 

Tropical  diseases  were  never  so  studied  as  they  have  been  by  the  Ame 
can  army.  Osier's  "Modern  Medicine"  will  acquaint  the  reader  so  well  with 
the  wonderful  advances  along  this  line  that  it  is  quite  unnecessary  to  discuss 
the  subject  here.  Unfortunately,  yellow  fever,  pellagra,  and  bubonic  plague 
have  reached  our  shores.  Cholera  is  a  menace  possible  with  us,  while  cattle 
diseases  seem  to  be  coming  to  us  from  foreign  shores.  The  victory  over  yellow 
fever  and  malaria  in  Panama  and  Cuba  and  of  the  hookworm  disease  in 
Puerto  Rico  are  largely  instances  of  the  scientific  attainment  and  courage  of 
the  army  medical  man.     And  within  our  own  country  at  home  the  record  of 


262  HYGIENE 

the  same  kind  of  men  in  preserving  us  from  bubonic  plague  is  an  earnest  of 
the  good  an  army  can  do.  Our  military  establishment  does  not  exist  solely 
to  fight  our  battles.  I  wish  that  it  were  possible  for  the  rank  and  file  of  phy- 
sicians to  receive  the  literature  of  our  government  departments  and 
especially  of  those  having  to  do  with  medicine.  As  an  author  and  medical 
librarian  I  have  these  publications  at  command,  and  they  have  made  me 
proud  of  my  country;  but  any  physician  can  get  them  at  cost  by  addressing 
the  Superintendent  of  Documents,  Government  Printing  Office,  Washington, 
D.  C.  And  it  seems  to  me  that  the  military  physician  who  has  accomplished 
so  much  in  the  prevention  of  tropical  diseases  might  be  a  good  man  to  inves- 
tigate the  unconquered  diseases  of  temperate  climes. 

Clothing. — This  subject  will  be  touched  upon  in  considering  the  naval 
regulations.  There  has  been  a  wonderful  change  in  military  uniforms  within 
the  last  few  years,  all  tending  toward  greater  practicability  and  sanitary  use- 
fulness. Persons  desiring  details  can  consult  the  regulations  governing  the 
matter. 

Marches. —  Did  you  ever  march  in  the  ranks  ?  There  is  very  little 
poetry  in  it  and  it  is  exceedingly  exhausting  work.  And  yet  it  is  necessary 
work.  The  mobile  army  is  usually  the  one  to  win  the  victory.  To  my 
mind,  the  march  could  be  rendered  more  easy.  There  are  military  men  who 
claim  that  the  "  martial  bearing  "  or  "  ramrod  attitude  "  is  not  good  for 
health.  While  this  sort  of  thing  and  many  other  fancy  postures  of  the  drill 
manual  look  pretty  and  are  supposed  to  make  a  soldier,  I  fail  utterly  in  seeing 
any  real  utility  in  that  sort  of  thing  and  think  it  time  to  stop  using  the  soldier's 
strength  preparing  for  parade  drill  and  indulging  in  what  the  women  regard 
as  heroics.  With  all  deference  to  the  ladies,  they  are  not  needed  about  mili- 
tary camps  and  show  good  taste  in  remaining  away  unless  they  come  to  work 
in  time  of  war  or  to  nurse  sick  men.  I  speak  advisedly  in  the  matter  and 
think  it  time  that  the  regulations  about  camp  visiting  generally  be  made 
more  stringent.  At  all  events,  removing  the  spectacular  and  the  appeal  to 
gallantry  would  puncture  a  lot  of  dress  drill  or  "  dress  parade,"  as  it  is  justly 
called.  What  the  soldier  needs  to  learn  is  how  to  take  care  of  himself  and 
make  it  dangerous  for  the  enemy.  Fancy  uniforms  have  largely  gone  and 
fancy  postures  and  drills  should  follow.  As  a  matter  of  fact,  they  are  going. 
"  Tell  it  not  in  Gath,"  but  I  have  really  seen  soldiers  upon  the  march  walking 
along  just  like  any  easy-going  pedestrian.  The  martial  bearing  need  not  be 
abolished,  but  a  sensible  officer  will  suspend  as  much  of  it  as  the  regulations 
will  permit.  Peary's  march  to  the  pole  should  be  an  object  lesson  to  the 
army.  The  long  practice  marches  recently  indulged  by  certain  commands 
have  nothing  to  commend  them,  but  a  sensible  and  regular  system  of  practice 
marches  strictly  within  the  capacity  of  the  men  should  be  highly  beneficial. 

The  canteen. —  Dr.  Anita  Newcomb  McGee,  formerly  acting  assistant 
surgeon,  United  States  Army,  conducted  an  elaborate  investigation  of  the 
canteen  and  reported  in  a  very  scientific  and  unbiased  way  her  conclusions. 
Her  statements  impress  me  as  the  most  temperate  and  well  advised  of  any- 
thing I  have  encountered  upon  the  subject.  Permit  me  to  state  her  postulates 
without  the  data  substantiating  them. 


ARMY  AND  NAVY  SANITATION  263 

1.  There  has  been  somewhat  less  drunkenness  in  the  army  since  the  canteen 
was  abolished  than  there  was  in  the  years  when  it  flourished. 

2.  The  difference  in  amount  of  alcoholism  during  the  canteen  years  (before 
1898),  and  that  during  the  post  canteen  years  is  so  slight  as  to  show  in  conjunction 
with  other  facts  that  the  presence  or  absence  of  the  canteen  has  a  decidedly  minor 
eflTect  on  drunkenness  in  comparison  with  other  influences. 

3.  There  was  an  enormous  increase  in  venereal  diseases  in  1899,  coincident  with 
tropical  service;  there  was  no  increase  in  the  United  States  in  the  four  years  following 
the  abolition  of  the  canteen,  as  compared  with  the  two  years  preceding  it.  In  the 
Philippine  Islands  there  was  an  absolutely  regular  increase  from  1896  to  1903. 

4.  The  increase  of  saloons  outside  army  posts,  which  was  so  generally  predicted 
to  follow  an  anti-canteen  law,  did  not  occur  at  all. 

5.  Desertions,  court-martials,  etc.,  are  due  to  so  many  causes  I  have  not  con- 
sidered them  worthy  of  thorough  analysis,  but  so  far  as  I  examined,  I  could  find  no 
pro-canteen  evidence. 

6.  The  statement  that  "  The  army  from  the  lowest  rank  up  is  (1907)  practically 
unanimous  in  its  desire  to  have  the  canteen  re-established  "  is  an  opinion,  the  proof 
of  which  I  could  not  obtain. 

7.  Quite  apart  from  the  canteen,  the  subject  of  drunkenness  and  immorality  in 
the  army  demands  attention.  International  medical  statistics  show  that  the  admission 
rates  of  alcoholism,  for  gonorrhoea,  and  (British  Army  excepted)  for  syphilis,  "  were 
much  higher  than  in  any  other  army."  (Surgeon  General's  Report,  1907,  pages  23 
and  26;  for  1906,  pages  22  and  24.) 

8.  Conclusions:  It  is  evident  that  I  have  only  scratched  the  surface  of  a  mine  of 
actual  fact.  But  the  great  difi^erence  shown  to  exist  in  the  different  arms  of  the  service 
leads  me  to  the  belief  that  if  army  officers  would  make  a  careful  study  of  the  facts 
much  could  be  done  to  reduce  the  amount  of  alcoholism,  and  it  is  for  this  reason  that 
I  have  yielded  to  repeated  urgings  to  set  forth  the  main  facts  which  I  have  learned, 
I  have  become  convinced  that  the  prohibition  sentiment  of  the  country  makes  the 
restoration  of  the  canteen  impossible.  The  sooner  we  forget  it  and  adopt  other 
methods  for  diminishing  alcoholism,  the  better  it  will  be  for  the  army. 

It  is  significant  that  many  officers  do  not  agree  with  Dr.  McGee.  Per- 
haps the  clubs  they  frequent  keep  up  a  canteen  sentiment,  and  what  is  good 
for  them  should  be  good  for  their  men.  The  American  officer  is  always 
"  generous  to  a  fault." 


Special  Naval  Regulations 

A  physician  who  knows  how  to  operate  a  lathe  or  run  an  engine  is  just 
as  much  impressed  with  the  mechanical  features  of  a  modern  warship  as  he 
is  with  the  sanitary  regulations.  From  some  examination  of  examples  of 
the  navies  of  several  nations,  I  confess  to  a  disappointment  in  the  former 
features.  Altogether  too  much  is  attempted  within  a  limited  space,  and  the 
whole  impressive  ensemble  is  that  of  a  machine  shop  needing  a  visit  from  the 
factory  inspector.  With  wireless  equipment,  submarine  features,  and  the 
ever  growing  addition  of  mechanical  devices,  the  whole  jumble  leads  one  to 
speculate  as  to  how  much  of  it  will  have  to  be  cast  overboard  when  stripping 
for  action  so  as  to  leave  room  to  man  the  guns.     It  is  like  a  house  so  full  of 


264  HYGIENE 

junk  as  to  leave  no  adequate  room  for  the  people,  or  a  factory  so  crowded 
with  machines  and  workmen  as  to  scarce  give  one  room  to  turn  around  or  get 
fresh  air.  To  the  mechanic  there  is  a  dangerous  proximity  of  diverse  ele- 
ments and  too  much  heavy  machinery  for  successful  handling  within  the 
space  at  command.  A  mere  boat  builder  cannot  but  regard  the  overweighted 
and  top-heavy  warship  as  a  sort  of  monstrosity.  The  man  apt  to  be  shot  at 
fears  more  from  splinters  and  broken  machinery  and  internal  explosions  than 
he  does  from  the  projectiles  of  the  enemy.  In  modern  construction  too  much 
depends  upon  maintaining  structural  integrity.  There  are  too  few  units  and 
too  much  mechanism.  It  is  like  two  hundred  trolley  cars  depending  upon 
one  power  plant;  slip  a  belt  and  the  whole  line  is  tied  up.  Some  day  (or 
more  likely  some  night)  half  a  dozen  such  leviathans  will  be  annihilated  by 
one  cruiser  and  a  fleet  of  submarines,  and  then  the  world  will  cease  building 
the  over-developed  typical  battleship  of  to-day. 

But  from  the  sanitary  point  of  view  there  are  features  to  commend. 
There  are  no  timbers  to  rot  out  and  no  inaccessible  places  for  filthy  bilge 
water  to  collect ;  a  man  with  an  electric  light  and  paint  pot  can  get  anywhere, 
even  between  the  double  bottoms;  there  are  few  places  to  harbor  vermin  or 
mosquitoes,  rats  are  readily  controlled  upon  such  vessels,  they  are  easy  of 
disinfection,  the  sick  bays  in  peace  are  ideal,  the  plumbing  and  sanitary  fea- 
tures are  beyond  criticism,  there  is  a  most  careful  inspection  of  provisions, 
and  there  is  an  abundance  of  hot  water  and  live  steam  for  sanitary  purposes. 
Simplify  the  naval  fight  and  reduce  the  range  of  work  required  of  a  vessel,  so 
as  to  reduce  machinery,  fittings,  and  weight  of  superstructure,  and  there 
could  hardly  be  a  better  health  resort  than  a  naval  fighting  machine  in  time 
of  peace. 

Aboard  a  warship  one  finds  ideal  care  as  to  foods.  Meats  are  in  cold 
storage  and  are  not  allowed  to  be  even  hung  up  to  thaw,  but  must  be  placed 
in  cold  water  for  this  purpose;  vegetables  and  fruits  are  most  carefully  washed 
before  peeling;  vegetables  eaten  raw  are  first  subjected  to  a  heat  of  one 
hundred  and  forty  to  one  hundred  and  sixty  degrees  if  from  an  oriental 
country,  where  human  excrement  is  used  as  fertilizer  an  inch  is  cut  oflF  the 
ends  of  bananas,  and  endless  trouble  is  taken  with  the  water  used  for  all 
purposes.  This  is  but  an  illustration  of  the  care  exercised.  Even  the  coal 
bought  is  inquired  into  as  to  the  health  of  the  region  from  which  it  came,  so 
that  cholera  and  other  pathogenic  germs  may  not  come  aboard. 

What  is  said  here  is  a  mere  indication  of  the  naval  problems.  Doubt- 
less many  persons  will  desire  to  pursue  the  matter  further.  Dr.  P.  M. 
Rixey,  Surgeon  General,  United  States  Navy,  informs  me  by  letter  that  the 
latest  book  upon  the  subject,  as  it  relates  to  the  United  States,  is  one  by 
Medical  Inspector  J.  D.  Gatewood,  U.  S.  N.,  entitled  "  Naval  Hygiene," 
and  published  by  Blakiston  &  Co.,  Philadelphia.  Dr.  Gatewood  is  one  of 
the  most  able  officers  in  the  service  and  his  book  is  very  authoritative.  This 
work  covers  the  broad  principles  involved,  and  is  a  scholarly  presentation  of 
the  matter  in  its  many  bearings.  The  book  called  "  Instructions  for  Medical 
Officers  of  the  United  States  Navy  "  is  a  one  hundred  and  fifty  page  volume 
(1909  edition)  issued  to  medical  officers  of  the  navy.     It  would  pay  any  phy- 


Hligi; 


*-«**: 


art-i^isw-iiftin^sa^s--  -?c»»» 


CAMP    OF    INSTRUCTION    AND    PROVISIONAL    TENT    HOSPITAL 
FORT  RILEY,  KANSAS 
ANOTHER    PORTION    OF    THE    SAME    CAMP 
FIELD    HOSPITAL    NO.     8    AND    AMBULANCE    COMPANY,    SAME    CAMP 

Courtesy  U.  S.  War  Department 


ARMY  AND  NAVY  SANITATION  265 

sician  to  read  it,  provided  it  is  attainable.  From  it  most  of  the  following  data 
is  derived,  as  I  do  not  feel  justified  in  the  expression  of  any  but  the  official  views 
as  regards  specific  regulations.  Criticism  of  structure  is  another  matter.  If 
you  want  some  pessimistic  reading  look  up  the  reports  of  medical  officers 
aboard  vessels  badly  injured  or  destroyed  in  action  during  the  naval  fights  of 
the  last  fifteen  years.  The  United  States  Navy  cannot  aflTord  to  largely  de- 
part from  conventional  models  until  there  is  a  general  international  agree- 
ment that  the  structural  defects  of  the  present  t}pe  of  vessels  be  eliminated. 
While  such  matters  are  not  settled  and  the  advocates  of  the  present  types 
are  so  sensitive  to  criticism,  it  is  not  fair  to  quote  naval  men  upon  the  matter, 
but  I  am  informed  that  most  of  the  "  navy  muckraking  "  is  based  upon  data 
from  constructors  here  and  abroad.  Certain  it  is  that  vessels  out  of  commis- 
sion and  practically  abandoned  by  the  navy  are  often  so  spick  and  span  in  ap- 
pearance that  I  cannot  help  but  feel  there  is  something  wrong  in  a  type  that  is 
so  soon  cast  upon  the  scrap  heap.  War  vessels  have  been  made  much  longer 
than  have  automobiles.  I  have  just  been  looking  at  1910  models  up  about 
Columbus  Circle,  and  can  find  very  little  change  in  the  new  cars.  The  sales- 
men tell  me  they  are  so  near  perfected  that  little  change  is  advisable  in  new 
models.  But  when  I  went  over  to  the  navy  yards  the  mechanics  were  in  a 
ferment  wondering  what  would  happen  next  year  to  make  obsolete  the  types 
of  this  year.  Down  in  the  Washington  navy  yards  I  found  them  remaking 
certain  mechanism  that  had  never  been  used  long  enough  to  get  limbered  up. 

One  day  when  aboard  a  warship  the  bandmaster  left  the  vessel  and  a 
medical  officer  laughingly  recounted  to  me  the  ideas  the  first  man  entertained 
as  to  musical  technic  and  the  extreme  professional  views  he  held  relative  to 
music  and  the  great  difficulty  in  rendering  "  the  soul  "  of  the  composition. 
The  medical  officer  had  just  been  telling  me  something  of  how  different  naval 
sanitation  was  from  any  other,  and  how  long  it  took  for  an  intelligent  man  to 
imbibe  the  highly  specialized  technic  involved.  It  reminded  me  of  my  own 
experience.  For  eight  years  I  had  charge  of  a  very  busy  and  well-equipped 
X-ray  laboratory  and  made  it  a  point  to  meet  the  operators  over  the  country 
who  were  publishing  results  I  never  secured,  and  explaining  how  the  usual 
operator  did  not  succeed  in  doing  these  remarkable  stunts  with  the  ray  because 
of  defective  technic.  I  found  most  of  these  enthusiasts  had  a  different  technic. 
I  never  published  my  results  with  the  ray;  they  were  too  mottled.  And  I 
have  noticed  that  the  naval  medical  officer  of  some  years'  experience  is 
a  very  modest  gentleman  and  can  tell  of  seveial  things  he  does  not  con- 
sider immutably  settled.  A  mere  observer  like  myself  cannot  judge  between 
differing  naval  points  of  view,  so  will  content  myself  now  with  a  resume 
of  matters  contained  in  the  book  of  instructions  before  referred  to. 

The  very  first  page  has  to  do  with  appropriations,  and  that  very  clearly 
proves  that  the  regulations  are  up  to  date.  And  if  any  one  thinks  that  the 
money  is  all  spent  in  getting  ready  to  fight,  he  is  mistaken,  for,  as  with  the 
army,  the  navy  does  a  host  of  things  in  time  of  peace  that  are  of  positive  use 
to  the  country.  Croakers  please  take  notice.  Our  navy  pays  a  host  of  me- 
chanics and  constructors,  keeps  up  a  coast  survey,  good  museums  and  labora- 
tories, and  adds  a  large  increment  to  the  sum  total  of  useful  human  knowl- 


266  HYGIENE 

edge,  maintains  hospitals,  buries  the  dead,  pubhshes  much  valuable  data, 
gives  instruction  along  sanitary  and  other  lines,  conducts  original  investiga- 
tions, looks  after  certain  insane  persons,  patronizes  a  host  of  industries,  and 
does  many  things  with  money  that  render  a  good  return  to  the  country  if  it 
never  fires  another  shot. 

To  enter  medical  service  of  navy. —  The  applicant  must  be  a  citizen  of  the 
United  States,  be  of  good  moral  character,  be  between  twenty-one  and 
thirty  years  of  age,  and  pass  a  nine  days'  examination,  guaranteeing  his 
physical  and  professional  fitness  to  enter  the  service,  and  that  he  possesses  a 
good  general  education.  The  examinations  are  rigid  but  practical,  and  what 
I  have  learned  of  them  make  me  believe  that  they  are  more  rational  and 
reasonable  than  are  a  good  many  medical  state  board  examinations.  Pro- 
motion is  earned  only  after  later  and  additional  examinations,  and  which 
works  to  keep  the  medical  officers  up  to  date  and  studious. 

Navy  medical  school. —  This  school  gives  a  course  of  instruction  lasting 
five  months  of  each  year  and  serves  as  a  post-graduate  school  of  instruction 
for  naval  medical  officers,  and  covers  such  subjects  as  are  of  value  in  increas- 
ing their  efficiency. 

Duties  of  the  medical  officer. —  He  gives  the  crew  weekly  instruction  in 
first  aid  and  personal  and  general  hygiene.  The  boys  get  plenty  of  good 
advice  as  to  the  use  of  intoxicants,  the  care  of  venereal  diseases,  etc.,  and  are 
taught  how  to  take  care  of  themselves  under  all  circumstances.  Asepsis  is 
well  drilled  into  the  men  and  tuberculous  cases  on  board  are  given  especial 
instruction.  The  medical  officer  also  takes  part  in  the  drills  and  keeps  the 
men  up  to  efficiency  in  the  medical  features  of  fire  drill,  collision  drill,  rescue 
drill,  and  clearing  ship  for  action.  There  are  additional  duties  at  recruiting 
rendezvous,  at  hospitals,  in  hospital  ships,  and  certain  board  duties.  Of 
course  he  attends  the  sick  and  looks  after  the  sanitation  of  his  station. 
There  are  numerous  regulations  regarding  the  hospital  corps,  nurses,  hos- 
pital ships,  and  many  other  duties  not  specifically  relating  to  sanitation,  and 
which  need  not  be  discussed  here. 

Enlistment. —  The  examination  of  the  recruit  is  such  an  elaborate  affair 
that  it  would  take  pages  to  outline  the  matter,  let  alone  give  any  adequate 
digest  of  the  methods  and  requirements.  I  note  that  persons  given  to  intoxi- 
cation are  now  rejected.  Added  to  the  elaborate  examination,  identification 
records  and  finger  prints  are  made  and  preserved  of  all  enlisted  men. 

Sanitary  regulations. —  These  regulations  provide  for  detailed  re- 
ports and  designate  a  number  of  duties  very  obvious  in  their  necessity,  such  as 
ship  ventilation,  etc.,  and  covering  hygiene  such  as  is  necessary  everywhere. 
The  work  especially  pertaining  to  shipboard  is  as  follows:  Distilled  water 
must  be  used  for  drinking  and  culinery  purposes  and  harbor  water  may  not 
be  used  upon  the  decks  where  sewage  enters  the  harbor,  or  where  epidemic 
disease,  such  as  cholera,  prevails.  There  are  regular  rules  as  to  temperature 
and  weather  conditions  decisive  of  the  kind  and  weight  of  clothing  to  be 
worn  and  the  use  of  awnings,  etc.  Bathing  over  the  ship's  side  is  allowed 
when  the  water  is  at  70  degrees  F.  Infected  ports  are  to  be  avoided,  and 
when  duty  calls  the  vessel  there  elaborate  precautions  are  taken.     Anchorage 


ARMY  AND  NAVY  SANITATION  267 

at  such  ports  is  selected  to  windward  and  the  shore  Hberty  is  Hmited  or 
abolished  during  the  stay  of  the  vessel.  Mail  is  watched  or  disinfected  and 
the  medical  officer  is  empowered  to  do  whatever  seems  necessary  for  safety. 

In  the  tropics  the  crew  is  rested  during  the  middle  of  the  day,  awnings  are 
freely  used,  mosquito  nets  are  in  constant  service,  clothing  is  changed  when  a 
man  gets  wet  from  rain,  the  sun  is  carefully  avoided,  and  especial  care  is  taken 
of  the  food  supply. 

Contagious  or  infectious  diseases  aboard  are  very  carefully  isolated,  and 
the  care  taken  is  similar  to  that  outlined  in  other  chapters  of  this  book,  only 
the  navy  inclines  toward  the  use  of  sulphur  fumigation  and  steam  sterilization 
more  than  do  health  boards.  The  scuttle-butt  cup  is  kept  submerged  in  a 
formalin  solution  (1-2500)  when  not  in  use,  but  especially  constructed  scuttle- 
butts are  coming  into  use  that  very  much  reduce  the  danger  of  infection  being 
conveyed  by  drinking  at  a  common  supply. 

Landing  parties  are  under  sanitary  regulations  similar  to  those  described 
in  the  earlier  sections  of  this  chapter,  only  the  regulations  are  imperative, 
and  such  matters  as  sterilizing  the  water  are  not  merely  suggested;  they  are 
directed  absolutely.  Insects  are  carefully  avoided  and  unnecessary  exposure 
of  the  men  to  the  sun,  rain,  and  dew  are  prohibited,  whether  the  drills  are  held 
or  not.  Camp  sites  are  not  used  twice  unless  absolutely  unavoidable. 
"  Under  no  circumstances  should  the  men  be  allowed  to  sleep  in  wet  clothing," 
and  they  are  shielded  from  the  sun,  are  not  allowed  to  go  with  bare  feet, 
meals  must  be  served  warm,  no  one  may  be  overworked,  and  the  whole  list 
of  regulations  impress  one  with  the  good  sense  and  humanitarianism  of  the 
orders. 

Hospitals,  shore  stations,  navy  yards,  newly  commissioned  ships,  and  all 
other  property  are  under  constant  regulation  too  complex  to  outline  in  detail 
here.  Careful  sanitary  observations  and  reports  of  all  places  visited  outside 
the  continental  limits  of  the  United  States  are  required,  and  are  sent  to  the 
Bureau  of  Medicine  and  Surgery. 

Quarantine. —  The  chapter  upon  quarantine  covers  the  matter  and  little 
need  be  said  here.     The  following  diseases  are  quarantinable: 

(a)  Cholera,  period  of  incubation,  five  days. 

(b)  Yellow  fever,  period  of  incubation,  five  or  six  days. 

(c)  Smallpox,  period  of  incubation,  fourteen  days. 

(d)  Typhus  fever,  period  of  incubation,  twelve  days. 

(e)  Plague,  period  of  incubation,  seven  days. 

(f)  Leprosy.  If  in  an  alien,  not  permitted  to  land.  If  a  citizen,  the  case  is  dealt 
with  according  to  the  state  laws  of  the  port  of  entry. 

This  list  can  well  be  commended  to  the  attention  of  sanitary  officials 
wanting  to  quarantine  a  very  extended  list  of  minor  diseases.  With  certain 
exemptions,  vessels  of  the  navy  entering  port  are  subject  to  quarantine  in- 
spection the  same  as  are  other  vessels.  Disinfection  is  along  lines  outlined  in 
the  chapter  upon  disinfection.  In  that  chapter  will  be  found  two  photo- 
graphs of  disinfecting  apparatus.  Both  of  them  were  taken  by  myself 
aboard   a   vessel  at  the   Staten   Island   Quarantine   Station.     As   indicated 


268  HYGIENE 

before,  sulphur  disinfection  is  very  largely  depended  upon  in  the  navy. 
Spaces  containing  machinery  are  first  arranged  so  that  metal  parts  may  be 
coated  with  vaseline.  Fabrics  are  removed,  from  the  apartments  and  the 
effort  is  made  to  reach  rats  and  vermin. 

I  find  that  formaldehyde  is  not  very  much  in  favor  in  the  navy.  It  is 
not  depended  upon  at  all  for  the  holds  of  vessels  and  has  the  disadvantage 
of  not  killing  vermin.  It  has  slight  penetration.  It  is  used  largely  for  fabrics 
and  in  apparatus  such  as  is  illustrated  in  Chapter  XVIII.  The  autoclave 
under  pressure  is  used,  formalin  and  calcium  chloride  being  used,  and  the 
gas  being  evolved  under  a  pressure  of  not  less  than  forty-five  pounds.  The 
autoclave  method  combined  with  sustained  dry  heat  (60  degrees  C.  for  one 
hour)  is  used  in  sterilizing  some  articles  and  in  disinfecting  baggage.  Chemi- 
cal disinfectants  are  used  as  in  general  sanitary  practice,  the  regulations 
specifying  details. 

For  the  destruction  of  mosquitoes,  the  following  methods  are  used: 

(a)  Sulphur  dioxide.     A  strength  of  one  per  cent  of  dry  gas  is  very  efficient. 

(b)  By  burning  pyrethrum.  Use  two  pounds  for  every  one  thousand  cubic  feet 
of  space,  allowing  an  exposure  of  four  or  five  hours.  After  using  pyrethrum  sweep  up 
the  stupefied  mosquitoes  and  burn  them. 

(c)  By  vapors  from  a  mixture  of  equal  parts  of  camphor  and  phenol,  using  about 
five  ounces  for  each  one  thousand  cubic  feet  of  space.  Put  camphor  and  phenol  in 
evaporating  dish,  and  heat  with  moderate  alcohol  flame.  A  fine  white  cloud  of  vapor 
is  evolved.  Inhalation  of  this  vapor  should  be  avoided.  If  inhaled  smoky  urine 
results. 

Insanity. —  There  is  a  government  hospital  for  the  insane  in  the  District 
of  Columbia.  That  institution  and  the  Mendocino  State  Hospital  of  Cali- 
fornia receive  the  cases  under  regulations,  copies  of  which  can  be  procured 
from  the  Bureau  of  Medicine  and  Surgery. 

And  now  to  return  to  my  own  humble  expression  of  opinion.  Navies 
generally  are  taking  an  increased  interest  in  the  humanities.  The  Geneva 
Convention  marked  the  end  of  wholesale  barbarity  in  navies.  I  have  no 
word  of  criticism  for  the  past,  but  the  world  moves  on  and  there  is  a  growing 
tendency  in  armies  and  navies  to  retire  the  old  saying,  "  War  is  hell."  That 
killing  and  maiming  will  continue  is  to  be  expected  in  the  nature  of  the  case, 
but  warfare  is  becoming  a  far  more  humanitarian  international  game  and 
civil  and  revolutionary  war  is  becoming  less  possible  and  probable  from  the 
necessity  for  procuring  expensive  and  elaborate  equipment  as  well  as  specially 
trained  men  in  many  lines. 

Any  one  who  takes  the  trouble  to  read  the  articles  of  the  convention  and 
their  further  elaboration  at  the  Hague  Peace  Conference  cannot  but  be 
impressed  with  the  humanitarian  advances  in  warfare,  and  a  physician  will 
realize  the  great  emphasis  laid  upon  camp  and  ship  hygiene  and  the  especial 
prerogative  and  liberties  accorded  to  the  medical  service  in  time  of  battle. 

Hospital  ships  are  becoming  a  factor  of  great  importance,  and  the  litera- 
ture is  extensive.  While  not  purely  a  matter  of  hygiene,  the  subject  interests 
physicians.  Dr.  J.  C.  Wise,  of  the  United  States  Navy,  contributed  a  very 
good  article  to  the  December,  1907,  number  of  The  Military  Surgeon.     The 


<T       hS 


ARMY  AND  NAVY  SANITATION  269 

Geiman  view  was  well  reflected  in  the  Dutch  Review  of  April,  1904,  the  Jap- 
anese reports  have  much  to  say  about  the  value  of  such  vessels,  at  the  Inter- 
national Red  Cross  Conference,  of  1902,  the  matter  was  well  discussed,  and 
again  in  1907,  Mr.  G.  H.  Makins,  F.R.C.S.  presented  a  most  elaborate 
paper. 

Medical  Director  Manly  H.  Simons,  U.  S.  N.,  is  reported  to  have  said : 

At  Santiago  the  only  time  we  were  struck  our  dispensary  was  wrecked.  One 
of  the  Spanish  cruisers  had  a  torpedo  in  its  tube  ready  to  fire,  and  by  some  means  the 
concussion  of  striking  shells  exploded  the  torpedo.  That  wrecked  the  only  place  that 
they  had  for  their  wounded,  and  they  were  badly  crippled.  That  is  the  inevitable  fate 
that  will  overtake  the  majority  of  sick  bays  placed  aboard  battleships.  The  ships  go 
at  a  high  rate  of  speed.  If  one  is  damaged  or  hauls  down  its  flag  in  a  few  moments 
it  is  out  of  the  sphere  of  the  fighting  and  the  hospital  ship  can  reach  it  in  a  very  few 
moments.  The  latter  should  be  large,  roomy,  and  not  top  heavy.  There  will  be  no 
trouble  about  taking  off  any  sick  or  wounded  in  any  sea  in  which  fighting  can  be 
carried  on.  No  provision  can  be  made  on  any  battleship  that  will  aiford  any  con- 
siderable degree  of  safety  for  the  wounded.  We  had  forty-six  to  forty-seven  of  the 
Spanish  sailors  on  board  after  the  fight.  The  noise  they  made,  especially  those  who 
were  more  scared  than  hurt,  was  terrible,  and  our  own  men  shrank  under  that  sight. 
Unless  a  man  has  been  through  many  campaigns  it  will  shake  his  courage.  The 
sooner  you  get  the  wounded  out  of  the  ship  the  better.  We  must  have  hospital  ships 
to  take  off  the  wounded  men  for  their  sakes  and  for  the  sake  of  the  men  who  are  not 
hurt.   No  amount  of  room  on  board  of  a  battleship  will  take  the  place  of  a  hospital  ship. 

To  the  mind  of  the  present  writer,  the  mild  criticism  as  to  construction 
indulged  at  the  beginning  of  this  section  is  of  even  less  importance  than  the 
fact  that  fighting  machines  cannot  make  proper  provision  for  the  sick  and 
wounded  during  an  action. 

This  paper  has  been  written  from  the  civilian  point  of  view  and  does  not 
pretend  to  present  the  highly  elaborated  ideas  of  the  navy  medical  officer. 
Lack  of  space  precludes  entering  into  matters  of  detail  of  naval  interest. 
On  the  whole  there  is  a  vast  deal  to  commend  in  the  medical  service  of  our 
navy,  but  a  civilian  cannot  but  be  impressed  with  the  seemingly  endless 
routine  of  reports  and  various  kinds  of  bureau  work.  That  sort  of  thing  has 
grown  up  and  the  cogs  seem  to  fit  very  well  and  the  machine  works  very 
smoothly.  Perhaps  it  is  all  necessary.  Personally,  I  fail  to  see  it  that  way, 
but  realize  that  I  may  be  mistaken.  Also  I  do  not  see  that  navy  hygiene 
presents  elements  any  more  difficult  to  grasp  than  does  municipal  hygiene, 
and  the  municipal  administration  is  rendered  doubly  difficult  by  the  obstruc- 
tive tactics  of  the  ignorant  politician.  This  the  navy  may  thank  its  kind 
stars  and  stripes  that  it  largely  avoids.  The  present  Secretary  of  the  Navy 
has  "  clipped  the  wings  "  of  the  bureau  chiefs  since  this  was  written. 

The  Public  Health  and  Marine  Hospital  Service  of  the  United 

States 

The  annual  report  of  the  Hon.  Walter  Wyman,  surgeon-general  of  this 
service  (1908),  is  the  basis  of  what  is  here  said,  tempered  somewhat  by  a  care- 


270  HYGIENE 

ful  personal  observation  of  the  work  and  a  reading  of  the  literature  of  the  ser- 
vice for  several  years  past. 

The  late  report  is  of  particular  importance  on  account  of  the  discussion 
of  the  work  in  plague  suppression  upon  the  Pacific  coast,  and  which  is  dis- 
cussed in  Chapter  VII  of  this  present  book.  The  matter  is  again  referred  to 
in  Chapter  IX,  under  California.  Hence,  the  plague  problem  will  not  be 
discussed  in  this  section,  except  to  say  that  the  matter  is  one  illustrative  of 
the  need  for  a  federal  health  service.  Any  one  who  reads  the  reports  of  the 
service  herein  discussed  will  realize  that  it  is  the  proper  nucleus  of  a  federal 
bureau  of  health. 

As  before  referred  to,  the  service  has  undertaken  much  work  relative  to 
the  purity  and  integrity  of  the  drugs  of  the  United  States  Pharmacopoeia, 
but  probably  its  greatest  service  has  been  an  investigation  of  vaccines  and 
serums.  The  recent  epidemic  of  foot  and  mouth  disease  in  several  of  the 
states  has  been  traced  to  impure  vaccine,  and  the  suppression  of  the  epidemic 
has  been  a  very  expensive  matter  to  the  states  involved.  No  such  products 
may  now  enter  the  country  unless  approved  by  the  service,  which  usually 
inspects  the  laboratory  making  the  products.  It  also  has  authority  governing 
interstate  traffic  in  vaccines  and  serums.  American  makers  must  comply 
with  certain  requirements  and  then  obtain  a  license.  Twelve  American 
makers  possess  such  licenses  and  an  equal  number  of  foreign  ones.  Exami- 
nations in  the  hygienic  laboratory  at  Washington  of  vaccine  virus  show  fav- 
orable results,  and  physicians  need  not  now  fear  that  approved  vaccine  con- 
tains tetanus  bacilli. 

Anti-diphtheritic  serum  is  all  standardized  by  methods  prescribed  and 
controls  that  are  supplied  by  the  division  of  pathology  and  bacteriology  of 
the  hygienic  laboratory,  and  a  careful  watch  is  kept  upon  the  marketed  pro- 
duct. Physicians  have  sent  to  the  laboratory  specimens  of  antitoxin  from 
which  bad  results  have  accrued,  and  in  no  such  instance  has  the  serum  been 
found  at  fault.     Quoting  from  the  report: 

The  results  of  the  examinations  in  the  hygenic  laboratory  showed  that  the  serums 
were  free  from  bacteria  contamination,  and  in  view  of  the  previous  work  done  along 
this  line  in  the  laboratory,  it  was  evident  that  the  untoward  symptoms  reported  were 
not  attributable  to  diphtheria  antitoxin  itself,  but  showed  that  the  patients  were  in  all 
probability  sensitized  in  some  as  yet  unknown  way  to  horse  serum.  The  phenomena 
of  hypersusceptibility  has  received  very  careful  study,  and  it  can  positively  be  stated 
that  diphtheria  antitoxin  plays  no  part  in  the  poisonous  action  of  horse  serum.  The 
symptoms  following  spaced  injection  of  horse  serum  in  animals  are  very  characteristic 
and  indicate  that  the  poisonous  principle  has  a  powerful  influence  upon  the  respiratory 
center.  Paralysis  of  the  respiratory  centers  is  evidenced  by  the  fact  that  respiration 
in  fatal  cases  ceases  long  before  the  heart  stops  beating. 

Read  what  is  said  upon  this  subject  in  the  chapter  upon  "  Immunity." 
Antitetanic  serum  has  been  notoriously  unreliable  until  the  service  took 
the  matter  up  and  required  standards.     Physicians  who  were  formerly  dis- 
appointed with  this  serum  should  try  again  and  they  will  find  that  the  serum 
now  marketed  is  at  least  potent.     Other  organo-therapeutic  products  are 


ARMY  AND  NAVY  SANITATION  271 

undergoing  examination  and  the  matter  of  the  standardization  of  drugs  is 
receiving  scientific  attention. 

Tuberculosis  work  in  many  of  the  states  is  upon  a  basis  very  far  from 
scientific,  and  the  public  are  being  filled  w^ith  fears  based  upon  assumptions 
and  the  enthusiastic  progagandism  of  certain  gentlemen  who  think  they  can 
diagnose  the  incipiency  of  the  disease  wholly  from  clinical  symptoms.  The 
service  is  puncturing  some  of  these  absurd  pretensions.  The  usual  thermal 
death  point  of  the  bacillus  has  been  determined  at  60  degrees  C.  for  twenty 
minutes.  It  is  found  not  more  resistant  to  heat  than  are  other  non-spore- 
bearing  bacteria.  Studies  upon  the  subject  are  being  continued  and  results 
thus  far  do  not  justify  some  of  the  current  pessimism. 

The  pollution  of  interstate  waterways  and  the  investigation  of  the  typhoid 
problem  have  furnished  data  for  anticipated  legislation,  promising  much  for 
public  health.  The  service  was  formerly  occupied  almost  wholly  with  army 
and  navy  sanitation,  but  is  gradually  assuming  the  functions  of  a  national 
board  of  health. 

Hookworm  disease  among  the  mill  workers  of  the  South  and  in  Puerto 
Rico  has  called  for  extensive  investigations  reflecting  great  credit  upon  the 
service.  The  full  report  upon  the  matter  will  be  available  before  this  present 
volume  is  in  print.  Advance  reports  show  that  one  hundred  and  thirty 
factories  were  visited.  A  rather  startling  state  of  affairs  is  indicated  in  one 
of  many  features  reported :  "  It  is  seen,  for  instance,  that  among  the  females 
of  maternity  age  from  thirteen  to  eighteen  per  cent  are  in  a  condition  which 
prevents  them  from  properly  nourishing  babes,  .  .  .  Among  children  of 
school  age,  generally  speaking,  18.7  per  cent  of  the  females,  and  29.4  per  cent 
of  the  males  are  suffering  from  an  anemia-producing  disease,  which  would 
materially  inhibit  their  normal  capacity  for  study."  It  has  been  thought 
that  breathing  in  the  lint  was  responsible  for  the  anemia,  but  the  fact  remains 
that  upon  clay  land  the  percentage  of  hookworm  disease  nearly  reached  the 
vanishing  point,  while  child  operatives  living  upon  sand  land  were  infected 
to  as  high  a  degree  as  80  per  cent.     And  now  just  think  of  this  statement: 

Doctor  Stiles  states  that  as  a  soil  polluter  the  negro  is  to  the  white  as  795  to  438; 
therefore  he  is  nearly  twice  the  spreader  of  hookworm  disease  when  compared  with 
the  white.  He  is  also  a  greater  relative  spreader  of  malaria,  because  he  screens  less 
against  mosquitoes.  The  conclusion  is  therefore  evident  that  the  white  race  in  the 
South  is  living  under  a  hygienic  handicap,  due  to  such  a  large  proportion  of  negro 
population. 

Rabies  is  another  disease  under  investigation  by  the  service.  The  serum 
treatment  of  Marie  and  the  Ferran  method  of  prophylaxis  are  being  inves- 
tigated, and  the  Pasteur  treatment  advanced. 

Pellagra  is  becoming  a  serious  menace  in  the  South  and  the  medical 
journals  are  reporting  many  deaths  therefrom.  Thus  far  the  fungus  sup- 
posedly producing  toxic  substances  in  corn  that,  when  eaten,  is  productive 
of  the  disease,  has  not  been  isolated.  Cases  should  be  reported  to  the  service 
for  investigation. 

The  studies  upon  milk  published  by  the  hygienic  laboratory  are  dis- 
cussed in  the  chapter  upon  rural  hygiene.     Many  lines  of  investigation  are 


272  HYGIENE 

under  way  and  the  laboratory  of  hygiene  is  not  only  doing  the  routine  work 
for  the  army  and  navy,  but  is  training  men  in  original  investigation.  The 
research  work  is  made  public  in  the  bulletins,  forty-nine  of  which  have  been 
issued.  I  have  more  or  less  carefully  gone  over  all  of  them  and  want  to  com- 
mend to  all  physicians  a  study  of  this  valuable  series. 

The  service  holds  conferences  with  state  and  territorial  health  officers 
as  well  as  with  the  officers  of  the  army  and  navy,  and  is  making  an  effort  to 
solve  the  difficulties  involved  in  interstate  and  international  quarantine,  and 
is  a  party  to  the  proposed  international  office  of  public  hygiene  at  Paris. 

Quarantine  has  a  separate  chapter  in  this  volume.  The  service  is  largely 
identified  with  quarantine  in  the  United  States  and  maintains  several  stations. 
Insular  quarantine  comes  under  its  supervision,  and  it  is  proposed  that  the 
service  undertake  all  maritime  quarantine  involving  this  country.  How- 
ever, there  are  certain  objections  to  be  offered.  Foreign  quarantine  is  re- 
flected in  the  weekly  bulletins  and  is  a  very  large  task,  involving  a  great  deal 
of  inspection  work  at  the  ports  all  over  the  world.  The  details  are  so  exten- 
sive that  the  reader  must  be  referred  to  the  official  "  Weekly  Health  Reports  " 
of  the  service.  The  medical  inspection  of  immigrants  is  given  a  separate 
section  elsewhere  in  this  present  volume.  I  have  seen  much  of  the  officers 
of  the  service,  and  our  country  can  be  proud  of  their  achievements  in  war 
and  peace. 

Other  Camps  —  Contractors'  Labor  Camps 

What  has  been  said  about  camps  in  the  army  and  navy  applies  here  to  a 
large  extent.  In  the  chapter  upon  "  Places  of  Amusement  and  Dissipation  " 
camp  meetings,  etc.,  are  referred  to. 

As  to  further  details  concerning  the  sanitation  of  contractors'  camps  I 
feel  that  I  can  do  no  better  than  to  reproduce  the  rules  and  regulations  of  the 
Department  of  Public  Health  and  Vital  Statistics  of  the  State  of  Texas. 

Lumbering  Camps,  Railroad  Construction  Camps,  Boarding  Cars,  Pleasure 
Camps  or  Resorts,  or  So-called  Open  Air  Health  Resorts 

Section  1.  The  owner,  manager,  agent,  or  foreman  of  any  lumbering  camp, 
mining  camp,  sawmill  camp,  railroad  boarding  car,  or  construction  camp,  pleasure 
camp  or  resort,  or  so-called  open  air  health  resort,  or  other  industry  requiring  the 
establishment  of  a  camp,  shall  be  responsible  for  the  proper  execution  and  enforce- 
ment of  any  regulation  herein  contained,  or  of  any  clause  of  any  health  regulation 
governing  any  case  or  circumstance. 

Sec  2.  Any  house,  boarding  car,  tent,  or  other  dwelling  occupied  by  the  em- 
ployees engaged  in  any  industry  shall  contain  at  least  three  hundred  cubic  feet  of  air 
space  for  each  occupant  thereof.  Every  such  dwelling,  other  than  a  temporary  tent 
not  exceeding  ten  by  twelve  feet,  shall  be  supplied  with  adequate  lighting,  and  in  all 
wooden  or  iron  structures  the  windows  must  be  so  constructed  that  they  can  be  readily 
opened. 

Sec  3.  Proper  ventilation  shall  always  be  provided,  and  a  suitable  number  of 
openings,  windows,  or  doors  shall  be  supplied  in  such  manner  that  three  thousand 
cubic  feet  of  air  per  hour  shall  be  available  for  each  occupant  of  each  dwelling. 


ARMY  AND  NAVY  SANITATION  273 

Sec.  4.  Every  camp  shall  be  supplied  with  a  building  or  tent  properly  constructed, 
and  set  apart  as  a  kitchen  or  cook  house,  and  having  a  dining  room  or  eating  room 
in  connection  therewith,  with  proper  conveniences  for  the  cleanliness  of  the  employes. 

Sec.  5.  Proper  buckets  should  always  be  kept  on  hand,  in  which  all  refuse, 
whether  liquid  or  solid,  can  be  placed,  and  the  refuse  must  be  removed  to  a  safe  distance 
from  the  kitchen  at  least  once  daily,  and  so  deposited  as  not  to  create  a  nuisance  or 
contaminate  the  drinking  water. 

Sec.  6.  Latrines,  or  earth,  or  other  closets,  located  not  less  than  one  hundred  and 
twenty-five  feet  distant  from  the  nearest  dwelling  or  kitchen,  shall  be  constructed  at 
every  camp  or  resort,  and  must  be  located  and  maintained  in  a  sanitary  condition 
satisfactory  to  the  authorized  health  officer,  especial  care  being  taken  that  the  contents 
thereof  or  drainage  therefrom  shall  enter  no  stream,  lake,  or  pond  whose  waters  are  or 
may  be  used  for  drinking  purposes. 

Sec.  7.  The  stables  in  connection  with  any  camp  or  resort  must  be  located  so  as 
not  to  contaminate  the  water  supply  of  the  camp  or  of  any  neighboring  community, 
and  must  not  be  less  than  one  hundred  and  twenty-five  feet  distant  from  the  nearest 
dwelling  or  kitchen.  In  large  camps  this  distance  may  be  increased,  if  thought  neces- 
sary, by  the  authorized  health  officer. 

Sec.  8.  The  locations  of  the  buildings  of  any  camp  shall  be  made  with  a  due 
regard  for  its  healthfulness,  and  any  new  camp  located  without  the  previous  approval 
of  the  authorized  health  officer  must  be  moved  to  a  proper  location,  if  afterward  the 
site  is  found  to  be  undrained,  unhealthful,  or  wanting  in  any  adequate  or  wholesome 
water  supply;  and  any  camp  or  dwelling,  if  proved  to  be  unsanitary  or  unhealthful, 
shall  have  instituted  such  drainage,  or  have  introduced  such  water  supply  as  is  satis- 
factory to  the  authorized  health  officer. 

Sec.  9.  Should  any  disease  of  any  contagious  nature,  as  defined  in  Appendix  C 
of  this  circular,  break  out,  a  hospital  building  or  tent  must  be  located  by  the  physician 
in  charge  of  the  patient,  in  a  position  satisfactory  to  the  county  health  officer  or  any 
officer  authorized  by  the  state  health  officer  to  inspect  the  said  camp  or  resort. 

Sec.  10.  In  case  of  an  epidemic  of  smallpox  or  other  said  infectious  disease,  or 
in  case  the  county  or  state  health  officer,  owing  to  threatened  epidemic,  deems  it  ex- 
pedient, the  owner,  manager,  foreman,  or  other  person  in  charge  of  any  camp  as  above 
designated  and  mentioned  shall  require  a  certificate  of  recent  successful  vaccination 
of  each  employee  when  he  is  engaged  by  the  company  or  its  agent;  and  where  evidence 
is  not  forthcoming,  it  shall  be  the  duty  of  said  agent,  owner,  manager,  or  foreman 
before  employing  any  person  to  obtain  such  evidence  of  such  vaccination. 

Sec.  11.  Should  any  suspected  communicable  disease,  as  defined  above,  break 
out  in  any  camp  or  resort,  the  owner,  foreman,  employer,  or  agent  in  charge  of  such 
camp  or  resort  shall  immediately  notify  the  state  health  officer  of  such  outbreak;  and 
the  owner,  foreman,  employer,  or  his  agent  in  charge  of  said  camp  or  resort  shall  be 
responsible  for  any  neglect  in  notifying  the  state  health  officer. 

Sec.  12.  It  shall  be  the  duty  of  said  foreman,  owner,  employer,  or  agent  in  charge 
of  said  camps  or  resorts  and  boarding  cars  at  regular  intervals  to  so  treat  the  inside 
walls  and  ceilings  of  said  boarding  cars  and  camp  houses  with  whitewash  every  three 
months,  or  paint  every  six  months,  or  other  equally  good  disinfectant;  the  floors 
thereof  must  be  scoured  with  concentrated  lye  or  other  good  disinfectant  at  such  inter- 
vals (twice  a  week)  that  the  said  cars  or  dwellings  shall  be  constantly  in  a  sanitary 
condition. 

Sec.  13.  The  owner,  foreman,  or  other  person  in  charge  of  aforesaid  camps, 
resorts,  or  boarding  cars,  when  abandoning,  breaking  up,  or  moving  same,  is  hereby 
required  to  fill  in  all  sinks,  cesspools,  pits,  or  other  excavations,  whether  containing 


274  HYGIENE 

liquid  or  solid  refuse,  and  otherwise  place  the  premises  so  occupied  in  proper  sanitary 
condition. 

Sec.  14.     All  city  and  county  health  officers  are  hereby  authorized  and  urged  to 
see  that  the  above  regulations  are  enforced  in  their  respective  cities  and  counties. 

The  lessons  the  general  practitioner  can  learn  from  the  army  and  na\'y 
should  be  obvious  to  all  such  as  have  read  the  foregoing  account.  The  key- 
note of  success  in  their  work  is  thoroughness  based  upon  scientific  data 
Nothing  is  guessed  at,  nothing  taken  for  granted,  no  unnecessary  risks  are  run, 
obedience  to  regulations  of  the  sanitary  officers  is  imperative,  politics  does  not 
harass  the  capable  official,  all  the  men  in  command  are  trained,  and  bump- 
tiousness gets  so  hard  a  fall  that  it  is  seldom  tried  a  second  time.  Any  phy- 
sician may  be  called  upon  to  take  a  place  in  the  handling  of  a  camp  in  time  of 
great  public  disaster.  Let  him  never  imagine  that  he  can  do  so  successfully 
unless  he  has  studied  somewhat  the  important  subject  of  military  hygiene. 

Note — For  an  up  to  date  presentation  of  military,  naval,  and  tropical  surgery 
and  the  hospital  ship,  see  Keen's  Surgery,  Vol.  IV. 


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Chapter  XIII 


THE  CORONER  AND  THE  PHYSICIAN 

A  discussion  of  his  status  in  law  —  The  importance  of  the  physician  knowing  the 
powers  of  the  coroner  in  his  own  county  or  city  —  What  a  physician  can  expect  of  a 
coroner  —  What  a  coroner  can  expect  of  a  physician  —  What  cases  to  report  to  the 
coroner  —  Final    remarks. 


OLD  English  law  provides  for  and  defines  the  duties  of  the  coroner, 
and  most  of  the  states  of  the  American  Union  have  followed  the 
general  principles  long  since  laid  down.  Some  cities  enact  special 
legislation  regulating  his  office,  especially  where  the  limits  of  the  city  and  the 
county  are  the  same.  These  city  laws  differ  somewhat  and  may  provide  for 
deputies,  coroner's  physicians,  and  a  force  of  detectives.  Such  a  law  is  in 
force  in  Philadelphia  and  doubtless  cities  desiring  copies  of  the  law  can 
obtain  the  same  from  the  office  there  or  wherever  special  legislation  has  been 
enacted.  In  general  a  coroner  is  a  county  official,  and  has  power  to  subpoena 
witnesses,  take  evidence,  make  arrests,  and  do  other  things  not  necessary  to 
discuss  here.  He  is  a  very  powerful  official  and  bears  a  certain  relationship 
to  the  sheriff  and  is,  in  most  places,  the  only  man  who  may  arrest  the  sheriff, 
unless  the  latter  official  be  taken  in  the  commission  of  crime.  Where  the 
cause  of  a  death  is  not  certainly  and  legally  determined,  it  is  the  duty  of  a 
coroner  to  make  an  inquiry  into  the  facts  surrounding  the  death.  If  in  his 
inquiry  he  finds  full  evidence  clearly  determining  the  matter,  he  may  issue  a 
death  certificate.  Such  disposition  is  frequently  made  of  the  case  since  many 
suicides  are  so  apparent,  and  many  deaths  come  suddenly  in  persons  known 
to  be  suffering  from  vital  diseases  and  the  end  come  without  medical  atten- 
dance. In  such  cases  the  coroner  is  the  only  person  who  may  issue  a  death 
certificate  and  the  same  is  accepted  by  the  health  authorities  for  record. 

Where  the  facts  are  not  such  as  in  his  judgment  warrants  the  issuance 
of  a  death  certificate  or  to  define  liability  for  the  death,  he  may  impanel  a 
jury  of  citizens  who  view  the  body  to  make  it  assured  that  the  party  is  dead, 
to  make  such  inquiries  as  may  be  necessary  to  establish  the  identity  of  the 
deceased,  to  define  the  cause  of  death  and  sometimes  to  determine  liability 
therefor.  The  general  principles  of  evidence  are  rigidly  applied  and  the 
findings  of  a  coroner's  jury  may  warrant  arrest  and  the  presentation  of  the 
evidence  to  the  grand  jury  and  finally  to  the  court.  These  all  involve  so 
much  of  a  legal  nature  that  persons  desiring  information  should  look  for  the 
same  in  legal  works,  the  books  upon  medical  evidence,  toxicology,  and  medical 
jurisprudence,  inclusive  of  the  many  points  involved  in  the  making  of  a  post 
mortem  examination.  The  matters  at  issue  do  not  concern  our  present 
inquiry,  but  there  is  a  dearth  of  authoritative  literature  upon  the  duties  of  the 
coroner's  office. 

The  importance  of  the  physician  knowing  the  powers  of  the  coroner  in  his 
own  county  or  city. —  In  law  the  word  of  the  physician  actually  in  personal 


276  HYGIENE 

attendance  upon  a  person  who  is  ill  and  who  may  die  is  accepted  as  com- 
petent evidence  as  to  the  cause  of  death;  but  there  are  distinct  exceptions 
every  physician  must  bear  in  mind.  Death  by  violence  (homicidal  or  acci- 
dental), by  poison,  by  suicide,  by  neglect,  from  unknown  cause,  or  without 
legal  medical  attendance,  must  be  reported  to  the  coroner.  Were  not  this 
the  case,  not  only  would  criminals  be  apt  to  escape  punishment  for  their 
crimes,  but  the  record  of  death  would  be  so  ill  defined  as  to  give  trouble  in 
many  directions.  The  sanitary  authorities  are  charged  with  the  recording 
of  all  deaths  and  such  record  must  stand  legal  tests.  When  the  physician  is 
not  in  actual  position  to  give  legal  weight  to  his  death  certificate,  he  should 
not  issue  one. 

Therefore,  this  book  is  not  in  position  to  define  the  obligation  of  the 
physicians  to  the  coroner's  office.  Every  physician  should  make  it  his  care 
to  learn  the  requirements  in  his  own  district.  The  only  safe  general  rule  is 
for  the  physician  to  take  no  risks.  If  he  has  not  personally  examined  within 
twenty-four  hours,  in  the  capacity  of  attending  physician,  the  person  who  has 
died  and  knows  that  said  living  person  was  suffering  from  a  disease  liable  to 
be  soon  fatal,  he  better  call  the  attention  of  the  coroner  to  the  death.  While 
some  reports  may  be  unnecessary,  it  is  better  to  err  upon  the  safe  side  than 
upon  the  other. 

What  a  physician  can  expect  of  a  coroner. —  First  of  all,  he  can  expect  the 
coroner  to  absolve  him  from  liability  in  case  of  sudden  death  and  in  which  he 
may  be  present  and  gossip  may  connect  his  name  in  an  unpleasant  manner. 
It  is  a  common  occurrence  for  a  reputable  physician  to  be  called  to  a  woman 
flooding  to  death  from  a  criminal  operation,  or  to  the  deathbed  of  a  person 
who  has  been  feloniously  assaulted,  or  who  has  endeavored  to  commit  suicide. 
When  we  find  ourselves  in  such  unpleasant  circumstances,  it  is  wise  to  send 
for  a  consulting  physician  and  for  the  coroner,  and  his  inquiry  will  soon 
absolve  the  innocent  physician.  A  physician  who  is  a  party  to  the  con- 
cealment of  crime  is  particeps  criminis,  just  like  anyone  else.  Professional 
secrecy  does  not  involve  our  compromising  our  own  liberty  or  innocence.  It  is 
the  duty  of  the  coroner  to  make  as  prompt  response  as  he  can  to  the  call 
of  the  physician.  Post  mortem  changes  may  soon  take  place  and  delay  may 
defeat  the  ends  of  justice.  In  the  rare  cases  in  which  sudden  death  may  be 
charged  to  a  surgical  operation  or  to  an  anaesthetic,  the  surgeon  cannot 
insist  upon  a  post  mortem  examination  for  his  own  protection,  but  the  coroner 
can  do  it  for  him  and  very  probably  relieve  him  of  all  blame.  Where  con- 
tagious disease  has  been  concealed  and  the  death  involves  the  necessary  pre- 
cautions, the  physician  can  save  all  controversy  with  the  family  and  the  sani- 
tary authorities  by  calling  the  coroner.  Besides  all  this,  there  are  occasional 
cases  of  conflict  between  physicians  or  between  the  physician  and  the  real  or 
pretended  relatives  of  the  deceased,  and  that  may  involve  one  in  quite  a  deli- 
cate position.  In  such  cases,  the  coroner  is  always  our  best  friend.  There 
is  no  occasion  for  the  physician  to  fear  the  coroner,  provided  he  has  done  his 
duty,  and  is  not  helping  some  one  to  pull  chestnuts  out  of  the  fire.  The  phy- 
sicians as  a  class  can  expect  the  coroner  to  aid  in  procuring  evidence  against 


THE  CORONER  AND  THE  PHYSICIAN  277 

malpractitioners,  and  the  health  authorities  can  expect  his  aid  in  keeping  the 
most  difficult  class  of  vital  statistics. 

What  a  coroner  can  expect  of  a  physician. —  Briefly,  he  can  expect  a  full 
and  frank  statement  of  everything  he  knows  that  may  help  in  arriving  at  a 
just  verdict  in  any  and  all  cases.  He  can  direct  a  physician  to  make  an 
examination  of  a  body,  perform  a  post  mortem  examination,  or  make  chemical 
analyses.  He  may  also  call  upon  a  physician  as  a  witness  in  ordinary  or  as 
an  expert.  A  coroner  need  not  be  a  physician,  but  may,  when  specific  city 
legislation  permits,  employ  a  regular  physician  and,  in  any  event,  give  war- 
rants upon  the  county  commissioners  for  such  medical  services  as  may  be 
really  necessary.  The  notifications  of  deaths  by  the  physician  is  mandatory. 
When  the  physician  has  notified  the  coroner  of  a  death,  only  the  latter  may 
issue  the  death  certificate,  unless  he  directs  the  physician  to  do  so. 

What  cases  to  report  to  the  coroner. —  This  depends  somewhat  upon  local 
regulations.  Sheriffs  must  have  the  coroner  issue  the  death  certificate  in 
cases  of  legal  execution.  Common  carriers  must  notify  him  of  corpses  found 
along  their  right  of  way,  or  of  persons  dying  suddenly  upon  their  property,  as 
well  as  those  killed  by  accident.  Reports  need  not  necessarily  come  from  a 
physician,  but  he  must  report  any  sudden  deaths  in  his  practice  unless  the 
case  has  been  ill  of  a  disease  liable  to  cause  death  at  any  time,  or  complica- 
tions arise  in  a  less  dangerous  disease.  If  the  physician  is  sure  of  the  cause 
of  death  and  has  attended  the  party  within  twenty-four  hours,  he  need  not 
report,  save  in  exceptional  cases.  Deaths  by  violence,  poison,  suicide,  or 
neglect,  or  of  persons  not  known,  must  be  reported. 

Final  remarks. — The  coroner  does  not  take  any  part  in  public  hy- 
giene, except  in  the  making  of  death  reports,  and  in  the  suppression  of  crimes 
that  incidentally  touch  upon  the  larger  questions  of  public  hygiene  in  its 
sociologic  side.  The  neglect  of  infants,  so  that  they  die,  the  criminal  care- 
lessness of  persons  and  corporations,  abortions,  and  infanticide  and  other 
questions  regarding  human  life  are  within  his  province. 


Chapter  XIV 
QUARANTINE* 

Definitions  —  Maritime  —  Port  regulations  —  Inspection  —  Ports  of  entry — 
Quarantining  of  vessels  —  Requirements  at  quarantine  —  Regulations  concerning 
cholera,  yellow  fever,  smallpox,  typhus  fever,  leprosy,  and  plague  —  Canadian  and 
Mexican  frontiers  -^  Disinfection  —  Interstate  quarantine  —  Maritime  quarantine 
maintained  on  lakes,  gulf,  and  rivers  —  Inland  quarantine  • —  Quarantine  in  the 
various  states. 

THE  word  quarantine  is  derived  from  quaranta,  meaning  forty,  and  was 
first  applied  to  the  period  of  detention  as  practiced  against  plague  in 
Marseilles  in  the  fourteenth  century. 

Quarantine  may  be  subdivided  into  maritime,  interstate,  state,  muni- 
cipal, and  house  quarantine,  depending  upon  the  extent  of  territory  that  is 
involved  in  the  application  of  the  measure.  Maritime  quarantine  relates  to 
the  measures  enforced  by  the  national  and  state  governments  to  prevent  the 
entrance  of  infected  persons,  ships,  or  merchandise.  These  measures  are 
applied  at  ports  of  entry  and  along  lines  of  communication  by  land  with  such 
ports. 

Interstate  quarantine  relates  to  the  measures  which  are  employed  by 
the  national  and  state  governments  to  prevent  the  transmission  of  infection 
from  one  state  to  another  through  infected  persons,  merchandise,  or  public 
conveyances.  These  measures  are  applied  in  such  a  way  as  to  prevent  the 
transportation  of  the  infection  from  the  infected  area  to  areas  that  are  free  from 
the  infection. 

State  quarantine  relates  to  the  measures  adopted  by  a  state  government 
to  prevent  the  introduction  of  infectious  persons  or  merchandise  into  the  state 
along  the  ordinary  routes  of  travel. 

Municipal  quarantine  relates  to  the  measures  adopted  by  a  municipality 
to  prevent  the  entrance  of  infected  persons  into  the  town,  and  consists  in  in- 
hibiting all  intercourse  with  the  infected  area. 

House  quarantine  relates  to  those  measures  which  are  applied  to  limit 
the  infection  to  certain  houses,  and  consists  in  inhibiting  intercourse  between 
the  occupants  of  the  house  and  those  living  outside  its  walls. 

Maritime  Quarantine 

The  machinery  employed  by  the  national  government  in  enforcing  quar- 
antine consists  of  inspection  stations  at  all  important  ports  of  entry  where 
ships  are  detained,  and  their  passengers,  crews,  and  merchandise  inspected 
and  isolated  in  case  they  do  not  show  a  clean  bill  of  health.  At  these  inspection 
stations  the  government  maintains  boarding  vessels  manned  by  experts  who 
inspect  the  vessels  and  enforce  the  quarantine  measures.  Here  quarters  are 
provided  for  the  treatment  of  the  sick  and  for  the  isolation  of  the  well  persons 

*Edited  from  data  secured  from  the  Laboratory  of  Hygiene,  University  of  Pennsylvania. 


QUARANTINE  279 

until  they  are  found  to  be  free  from  infection.  Appliances  are  also  provided 
for  the  disinfection  of  the  vessels  and  their  cargoes.  The  appliances  for  dis- 
infection include  arrangements  for  the  mechanical  cleansing  of  vessels  and  for 
the  use  of  steam,  formaldehyde,  sulphur  dioxide,  and  disinfecting  solutions 
as  may  be  indicated  by  the  nature  of  the  infection. 

Regulations  at  Ports  of  Departure 

The  quarantinable  diseases  are  cholera,  yellow  fever,  smallpox,  typhus 
fever,  leprosy,  and  plague.  Vessels  coming  from  foreign  ports  must  show  a 
clean  bill  of  health  with  regard  to  these  diseases,  which  bill  of  health  is  issued 
by  the  resident  consular  officer  of  the  port  of  departure. 

Masters  of  vessels  departing  from  any  foreign  port,  or  from  any  port  in 
the  possessions  or  other  dependencies  of  the  United  States  for  a  port  in  the 
United  States  or  its  possessions  or  other  dependencies,  must  obtain  a  bill  of 
health,  in  duplicate,  signed  by  the  proper  officer  or  officers  of  the  United 
States  as  provided  for  by  law. 

Vessels  plying  between  Canadian  ports  on  the  St.  Croix  River,  the  St. 
Lawrence  River,  the  St.  Clair  River,  and  adjacent  ports  of  the  United  States 
on  the  same  waters;also  vessels  plying  between  Canadian  ports  on  the  follow- 
ing named  lakes,  viz.,  Ontario,  Erie,  St.  Clair,  Huron,  Superior,  Rainy  Lake, 
Lake  of  the  Woods,  and  Lake  Champlain,  and  ports  of  the  United  States;  also 
vessels  plying  between  Mexican  ports  on  the  Rio  Grande  River  and  adjacent 
ports  in  the  United  States,  are  exempt  from  the  foreign  regulations.  During 
the  prevalence  of  any  of  the  quarantinable  diseases  at  the  foreign  port  of 
departure,  vessels  above  referred  to  are  required  to  obtain  from  the  consular 
officer  of  the  United  States,  or  from  the  medical  officer  of  the  United  States, 
when  such  officer  has  been  detailed  by  the  President  for  this  purpose,  a  bill  of 
health,  or  a  supplemental  bill  of  health,  in  duplicate,  in  the  form  prescribed 
by  the  Secretary  of  the  Treasury. 

The  officer  issuing  the  bill  of  health  shall  satisfy  himself,  by  inspection  if 
necessary,  that  the  conditions  certified  to  therein  are  true,  and  is  authorized 
in  accordance  with  the  law  to  withhold  the  bill  of  health  or  the  supplemental 
bill  of  health  until  he  is  satisfied  that  the  vessel,  the  passengers,  the  crew,  and 
the  cargo  have  complied  with  all  the  quarantine  laws  and  regulations  of  the 
United    States. 

Inspection  is  Required  of 

(a)  All  vessels  from  ports  at  which  cholera,  yellow  fever,  or  plague  pre- 
vails, or  at  which  smallpox  or  typhus  fever  prevails  in  epidemic  form. 

(b)  All  vessels  carrying  steerage  passengers;  but  need  only  include  the 
inspection  of  such  passengers  and  their  living  apartments,  if  sailing  from  a 
healthy  port. 

Inspection  of  the  vessel  is  such  an  examination  of  the  vessel,  cargo,  pas- 
sengers, crew,  personal  effects  of  same,  including  examination  of  manifests 
and  other  papers,  food  and  water  supply,  the  ascertainment  of  its  regulations 
with  the  above,  the  manner  of  loading  and  possibilities  of  invasion  by  small 


280  HYGIENE 

animals  as  will  enable  the  inspecting  officer  to  determine  if  these  regulations 
have  been  complied  with. 

The  officer  making  the  inspection  will  preserve  in  his  office  a  record  of 
each  inspection  made  and  of  each  immunity  certificate  given;  a  copy  of  each 
certificate  of  disinfection  and  of  each  bill  of  health  issued.  A  weekly  report 
of  the  transactions  of  his  office  shall  be  forwarded  to  the  surgeon-general  at 
Washington,  D.  C. 

Regulations  at  Ports  of  Entry 

The  national  government  maintains  quarantine  and  inspection  stations 
at  the  following  places:  Portland,  Me.;  Boston,  Mass.;  New  York,  N.  Y. ; 
Perth  Amboy,  N.  J.;  Delaware  Breakwater,  and  Reedy  Island,  Del.;  Alex- 
andria, and  Cape  Charles,  Va.;  Cape  Fear,  Newbern,  and  Washington, 
N.  C;  Charleston,  Georgetown,  Beaufort,  and  Port  Royal,  S.  C;  South 
Atlantic,  and  Savannah,  Ga.;  Cumberland  Sound,  St.  John's  River,  Biscayne 
Bay,  Knight's  Key,  Key  West,  Punta  Rossa,  Bocagrande,  Tampa  Bay,  Port 
Ingles,  Cedar  Keys,  St.  George's  Sound,  and  Pensacola,  Fla.;  Fort  Morgan, 
Ala.;  Gulf  Quarantine,  Miss.;  New  Orleans,  La.;  San  Francisco,  San 
Diego,  San  Pedro,  Port  Los  Angeles,  Santa  Barbara,  Port  Hartford,  and 
Eureka,  Cal.,  Casco  Bay,  Newport,  Florence,  and  Columbia  River,  Ore.; 
Port  Townsend  and  Port  Angeles,  Wash.;  Dutch  Harbor  and  Nome,  Alaska. 

Every  vessel  subject  to  quarantine  inspection,  enteringa  port  of  the  United 
States,  its  possessions  or  dependencies,  shall  be  considered  in  quarantine  until 
given  free  pratique.  Such  vessels  shall  fly  a  yellow  flag  at  the  foremost  head 
from  sunrise  to  sunset,  and  shall  observe  all  the  other  requirements  of  vessels 
actually  quarantined. 

Vessels  arriving  at  ports  of  the  United  States  under  the  following  condi- 
tions shall  be  inspected  by  a  quarantine  officer  prior  to  entry: 

(a)  All  vessels  from  foreign  ports  except  those  coming  from  Canadian 
and  Mexican  ports,  (b)  Any  vessel  with  sickness  on  board,  (c)  Vessels 
from  domestic  ports  where  cholera,  plague,  or  yellow  fever  prevails,  or  where 
smallpox  or  typhus  fever  prevail  in  epidemic  form,  (d)  Vessels  from  ports 
suspected  of  infection  with  yellow  fever,  having  entered  a  port  north  of  the 
southern  boundary  of  Maryland  without  disinfection,  shall  be  subjected  to  a 
second  inspection  before  entering  any  ports  south  of  said  latitude  during  the 
quarantine  season  of  such  port. 

Inspection  at  Ports  of  Entry 

The  inspection  of  vessels  required  by  these  regulations  shall  be  made 
between  sunrise  and  sunset,  except  in  case  of  vessels  in  distress. 

In  making  the  inspection  of  a  vessel,  the  bill  of  health  and  clincial  record 
of  all  cases  treated  during  the  voyage,  crew  and  passengers'  lists  and  mani- 
fests, and,  when  necessary,  the  ship's  log  shall  be  examined.  The  crew  and 
passengers  shall  be  mustered  and  examined  and  compared  with  the  lists  and 
manifests  and  any  discrepancies  investigated. 


QUARANTINE  281 

After  arrival  at  a  quarantine  station  of  a  vessel  carrying  immigrants, 
and  upon  w^hich  there  has  appeared  during  the  last  voyage  a  case  of  cholera, 
smallpox,  typhus  fever,  or  plague,  and  after  quarantine  measures  provided 
by  regulations  of  the  treasury  department  have  been  enforced  and  the  vessels 
given  free  pratique,  the  facts  are  transmitted  by  the  quarantine  officer  to  the 
commissioner  of  immigration  at  the  port  of  arrival,  who  transmits,  by  mail 
or  telegraph,  to  the  state  health  authorities  of  the  several  states,  to  which 
immigrants  from  said  vessel  are  destined,  the  date  of  departure,  route,  num- 
ber of  immigrants,  and  the  point  of  destination  in  the  respective  states  of  the 
immigrants  from  said  vessel,  together  with  the  statement  that  said  immi- 
grants are  from  a  vessel  which  has  been  subject  to  quarantine  by  reason  of 
infectious  disease,  naming  the  disease.  This  information  is  furnished  to 
state  health  officers  for  the  purpose  of  enabling  them  to  maintain  such  sur- 
veillance over  the  arriving  immigrants  as  they  may  deem  necessary. 

When  a  vessel  arriving  at  quarantine  has  on  board  any  of  the  communi- 
cable but  unquarantinable  diseases,  the  quarantine  officer  shall  promptly 
inform  the  local  health  authorities  of  the  existence  of  such  disease  aboard  and 
shall  make  every  effort  to  furnish  such  notification  in  ample  time,  if  possible, 
to  permit  of  the  case  being  seen  by  the  local  authorities  before  discharge  from 
the  vessel. 

Quarantining  of  Vessels 

Vessels  arriving  under  the  following  conditions  shall  be  placed  in  quar- 
antine: 

(a)  With  quarantinable  disease  on  board  or  having  had  such  disease  on 
board  during  the  voyage. 

(b)  Any  vessel  which  the  quarantine  officer  considers  infected. 

(c)  If  arriving  at  a  port  south  of  the  southern  boundary  of  Maryland  in 
the  season  of  close  quarantine.  May  1  to  November  1,  directly  or  via  a 
northern  port,  from  a  tropical  American  port,  unless  said  port  is  known  to  be 
free  from  yellow  fever. 

(d)  In  the  case  of  vessels  arriving  at  a  northern  port  without  sickness 
on  board  from  ports  where  yellow  fever  prevails,  the  personnel  shall  be 
detained  under  observation  at  quarantine  to  complete  five  days  from  the  port 
of  departure. 

(e)  Towboats  and  other  vessels  having  had  communication  with  vessels 
subject  to  quarantine  shall  themselves  be  quarantined  if  they  have  been  ex- 
posed to  infection. 

Vessels  arriving  under  the  following  conditions  need  not  be  quarantined: 

(a)  Vessels  from  yellow  fever  ports  bound  for  ports  in  the  United  States 
north  of  the  southern  boundary  of  Maryland,  with  good  sanitary  condition  and 
history,  having  had  no  sickness  on  boaid  at  ports  of  departure,  en  route  or  on 
arrival,  provided  they  have  been  five  days  from  last  infected  or  suspected  port. 

(b)  Vessels  engaged  in  the  fruit  trade  may  be  admitted  to  entry  without 
detention,  provided  that  they  have  complied  in  all  respects  with  the  special 
rules  and  regulations  made  by  the  secretary  of  the  treasury  with  regard  to 
vessels  engaged  in  said  trade. 


282  HYGIENE 

Requirements  at  Quarantine 

No  direct  communication  shall  be  allowed  between  any  vessel  in  quar- 
antine and  any  person  or  place  outside  and  no  communication  whatever 
between  quarantine  or  any  other  vessel  in  quarantine  and  any  person  or  place 
outside,  except  under  the  supervision  of  the  quarantine  officer. 

Pilots  will  be  detained  in  quarantine  a  sufficient  time  to  cover  the  period 
of  incubation  of  the  disease  for  which  the  vessel  is  quarantined,  if,  in  the 
opinion  of  the  quarantine  officer,  such  pilots  have  been  exposed  to  infection. 

No  presumably  infected  ballast  shall  be  allowed  to  leave  the  quarantine 
station  until  disinfected. 

After  a  vessel  has  been  rendered  free  from  infection,  it  may  be  furnished 
with  a  fresh  crew  and  released  from  quarantine,  while  all  or  part  of  the  per- 
sonnel is  detained. 

The  persons  detained  shall  be  inspected  by  the  physician  twice  daily,  and 
be  under  his  constant  surveillance,  and  no  intercourse  will  be  allowed  between 
different  groups  while  in  quarantine. 

In  any  group  in  which  communicable  disease  appears,  the  sick  will  be 
immediately  isolated  in  hospital,  and  the  remaining  persons  in  the  group 
and  their  effects  appropriately  treated  and  then  removed  to  other  quarters,  if 
possible,  and  the  compartments  disinfected. 

No  convalescent  shall  be  discharged  from  quarantine  until  after  a  suffi- 
cient time  has  elapsed  to  insure  his  freedom  from  infection,  and  this  is  to  be 
determined  by  bacteriologic  examination  where  possible. 

The  body  of  no  person  dead  of  quarantinable  disease  shall  be  allowed  to 
pass  through  quarantine  until  one  year  has  elapsed  since  death.  Such  bodies 
must  be  transported  in  hermetically  sealed  coffins,  the  outsides  of  which  have 
been  carefully  disinfected. 

In  the  case  of  the  bodies  of  such  persons  as  may  have  died  on  the  voyage 
or  upon  arrival  at  quarantine,  cremation  should  be  resorted  to  if  practicable 
and  consented  to;  if  not,  the  body  should  be  wrapped  without  preliminary 
washing  in  a  sheet  saturated  with  a  solution  of  bichloride  of  mercury  1  to 
500  and  buried,  surrounded  by  caustic  lime. 

The  quarantine  officer  shall  report  to  the  collector  of  customs  any  ves- 
sel which  arrives  without  the  bill  of  health  herein  before  prescribed. 

Special  Regulations  on  Account  of  Cholera 

For  the  purpose  of  these  regulations  five  days  shall  be  considered  as  the 
period  of  incubation  of  cholera. 

If  the  vessel  carry  persons  from  cholera-infected  ports  or  places,  a 
bacteriologic  examination  should  be  made  of  any  cases  of  diarrhea  to  exclude 
cholera  before  granting  pratique. 

If  cholera  has  appeared  on  board,  remove  all  passengers  from  the  vessel 
and  all  of  the  crew,  save  those  necessary  to  care  for  her,  and  the  sick  are  placed 
in  hospital. 

Those  especially  suspected  are  carefully  isolated,  and  the  remainder  are 


BOAT  LANDING,  OFFICES,  AND  LABORATCJKV,  QUARANTINE 
STATION    AT    STATEN    ISLAND,    PORT    OF    NEW    YORK 


QUARANTINE  283 

segregated  into  small  groups.  Those  believed  to  be  especially  capable  of 
conveying  infection  must  not  enter  the  place  of  detention  until  they  are 
bathed  and  furnished  w^ith  non-infected  clothing;  nor  shall  any  material 
capable  of  conveying  infection  be  taken  into  the  place  of  detention,  especially 
food  and  water. 

The  water  and  food  supply  must  be  strictly  guarded  to  prevent  con- 
tamination, and  issued  to  each  group  separately.  No  fruit  or  uncooked 
vegetables  shall  be  permitted. 

The  greatest  care  must  be  exercised  to  prevent  the  spread  of  the  infection 
through  the  agency  of  flies  or  other  insects.  The  dejecta  from  all  persons  in 
quarantine  on  account  of  cholera  shall  be  disinfected  before  final  disposition. 

The  baggage  or  effects  of  passengers  and  crew  that  may  have  been  ex- 
posed to  infection  must  be  disinfected.  Articles  of  cargo  which  have  been 
exposed  to  infection  and  are  liable  to  convey  the  same  must  be  disinfected. 

Living  apartments  and  their  contents  and  such  other  portions  of  the 
vessel  as  have  been  exposed  to  infection  must  be  disinfected. 

Water  ballast  taken  on  at  a  cholera-infected  port  should  be  discharged  at 
sea,  or  if  discharged  in  fresh  or  brackish  water,  must  be  previously  disinfected. 
Vessels  arriving  with  water  ballast  presumably  infected  must  return  to  sea 
under  guard  in  order  to  discharge  such  ballast.  If  practicable,  the  tanks 
should  be  disinfected  before  being  flushed,  and  refilled  with  sea  water. 

Special  Regulations  on  Account  of  Yellow  Fever 

For  the  purpose  of  these  regulations,  five  days  shall  be  considered  as  the 
period  of  incubation  of  yellow  fever. 

Where  practicable  the  sick  are  removed  to  hospital,  and  all  persons  not 
required  for  the  care  of  the  vessel  are  also  removed  and  isolated.  The  per- 
sonnel of  the  vessel  shall  be  detained  five  days  from  completion  of  disinfection, 
or  if  they  have  been  removed  before  disinfection  of  the  vessel,  their  detention 
shall  begin  from  last  possible  exposure  to  infection.  In  stations  south  of  the 
southern  boundary  of  Maryland  detention  must  be  extended  to  six  days. 

If  the  vessel  has  in  all  respects  complied  with  the  quarantine  regula- 
tions to  be  observed  at  foreign  ports  in  such  cases,  and  has  been  disinfected 
under  the  supervision  of  an  accredited  medical  officer  of  the  United  States  at 
the  port  of  departure,  she  may,  upon  arrival  at  her  port  of  destination  in  the 
United  States,  with  good  sanitary  history  and  in  good  condition,  be  subject 
to  the  following  treatment: 

(a)  If  arriving  in  five  days  or  less,  she  may  be  admitted  to  pratique  with- 
out disinfection  or  further  detention  than  is  necessary  to  complete  the  five 
days. 

(b)  If  arriving  after  five  and  within  ten  days,  she  may  be  immediately 
fumigated  and  admitted  without  detention. 

(c)  If  arriving  after  a  longer  voyage  than  ten  days,  she  shall  be  treated 
as  if  she  had  not  been  subjected  to  any  previous  treatment. 

Passenger  traffic  without  detention  may  be  allowed  during  the  close 
quarantine  season,  May  1  to  November  1,  from  ports  infected  with  yellow 


284  HYGIENE 

fever  to  ports  in  the  United  States  south  of  the  southern  boundary  of  Mary- 
land, under  the  following  conditions: 

(a)  Vessels  to  be  of  iron  or  the  best  class  of  wooden  vessels,  and  to  be 
cleaned  immediately  prior  to  taking  on  passengers.  The  officer  issuing  the 
bill  of  health  to  these  vessels  shall  withhold  the  same  if  the  vessel  is  not  in 
first-class  sanitary  condition  and  complying  in  every  respect  with  the  condi- 
tions. 

(b)  The  vessel  must  lie  at  approved  moorings  in  the  open  harbor;  must 
not  approach  the  wharves,  nor  must  the  crew  be  allowed  ashore  at  the  port 
of  departure.  Every  possible  precaution  must  be  taken  to  prevent  the  ingress 
of  mosquitoes,  and  to  provide  for  the  destruction  of  these  should  they  find 
ingress. 

All  passengers  and  crew  must  be  immune  to  yellow  fever,  and  so  certified 
by  the  United  States  medical  officer.  The  evidence  of  immunity  which  may 
be  accepted  by  the  sanitary  inspector  is:  First,  proof  of  previous  attack  of 
yellow  fever;  second,  proof  of  continued  residence  in  an  endemic  focus  of 
yellow  fever  for  ten  years. 

Special  Regulations  on  Account  of  Smallpox 

For  the  purpose  of  these  regulations,  fourteen  days  shall  be  considered 
as  the  period  of  incubation  of  smallpox. 

On  all  vessels  arriving  with  smallpox  on  board,  or  having  had  small- 
pox on  board  during  the  voyage,  any  of  the  personnel  who  have  been  exposed 
to  the  infection  of  the  disease  must  be  vaccinated  or  detained  in  quarantine 
not  less  than  fourteen  days,  unless  they  show  satisfactory  evidence  of  recent 
successful  vaccination  or  of  having  had  smallpox. 

Vessels  arriving  with  smallpox  on  board  which  has  been  properly  iso- 
lated and  other  sufficient  precautions  taken  to  prevent  the  spread  of  the  dis- 
ease need  not  be  quarantined  further  than  the  removal  of  the  sick,  the  disin- 
fection of  all  compartments,  baggage,  and  objects  that  have  been  exposed  to 
the  liability  of  infection,  as  well  as  the  vaccination  of  the  personnel. 

On  vessels  arriving  with  smallpox  on  board  and  where  the  proper  iso- 
lation and  other  precautions  have  not  been  taken,  all  those  whom  the  quar- 
antine officer  believes  to  have  been  exposed  to  the  infection  will  be  detained 
unless  they  have  had  smallpox  or  unless  they  show  satisfactory  signs  of  having 
been  properly  vaccinated  within  one  year. 

Living  compartments  and  their  contents  or  any  other  pait  of  the  vessel 
exposed  to  the  infection  must  be  disinfected.  The  baggage  and  effects  of 
passengers  and  crew  that  have  been  exposed  to  infection  must  be  disinfected. 

Special  Regulations  on  Account  of  Typhus  Fever 

For  the  purpose  of  these  regulations  twelve  days  shall  be  considered  as 
the  period  of  incubation  of  typhus  fever. 

Vessels  in  otherwise  good  sanitary  condition,  but  having  typhus  fever  on 
board  which  has  been  properly  isolated,  need  not  be  quarantined  further  than 
the  removal  of  the  sick,  and  disinfection  of  the  compaitments  and  their  con- 
tents exposed  to  infection. 


QUARANTINE  285 

If  the  case  has  not  been  isolated,  or  the  disease  has  spread  on  board 
from  person  to  person,  the  vessel  will  be  quarantined,  the  sick  removed,  and 
those  w^ho  have  been  exposed  to  the  infection  detained  under  observation. 

Vessels  in  bad  sanitary  condition,  on  which  the  disease  has  appeared, 
will  be  quarantined  until  thoroughly  cleaned  and  disinfected  throughout; 
the  sick  will  be  cared  for  at  isolated  hospitals,  and  those  exposed  to  the  infec- 
tion detained  under  observation. 

The  baggage  and  effects  of  passengers  and  crew  that  have  been  exposed 
to  the  infection  must  be  disinfected.  Living  compartments  and  their  con- 
tents, or  any  other  parts  of  the  vessel  exposed  to  infection  must  be  disinfected. 

Special  Regulations  on  Account  of  Leprosy 

Vessels  arriving  at  quarantine  with  leprosy  on  board  shall  not  be  granted 
pratique  until  the  leper  with  his  or  her  baggage  has  been  removed  from  the 
vessel  to  the  quarantine  station.  No  alien  leper  shall  be  landed.  If  the  leper 
is  an  alien  passenger  and  the  vessel  is  from  a  foreign  port,  action  will  be  taken 
as  provided  by  the  immigration  laws  and  regulations  of  the  United  States. 

If  the  leper  is  an  alien  and  a  member  of  the  crew  and  the  vessel  is  irom  a 
foreign  port,  said  leper  shall  be  detained  at  the  quarantine  at  the  vessel's 
expense  until  taken  aboard  by  the  same  vessel  when  outward  bound.  Such 
case  of  leprosy  should  be  promptly  reported  to  the  collector  of  customs  at 
the  port  of  arrival  of  the  vessel,  and  the  collector  shall  exact  a  bond  from 
the  vessel  for  the  reshipment  of  the  said  alien  leper  upon  the  departure  of  the 
vessel. 

Special  Regulations  on  Account  of  Plague 

For  the  purpose  of  these  regulations  seven  days  shall  be  considered  as 
the  period  of  incubation  of  plague. 

In  those  actually  exposed  to  the  infection  of  plague  the  administration  of 
antipest  serum  is  regarded  as  a  valuable  prophylactic  measure;  for  the  pre- 
vention of  the  introduction  of  plague  into  a  community  liable  to  the  intro- 
duction of  plague  through  commercial  intercourse,  immunization  by  Haff- 
kine's  prophylactic  is  to  be  recommended. 

Vessels  infected  with  plague,  or  suspected  of  such  infection,  should  be 
anchored  at  a  sufficient  distance  from  the  shore  or  other  vessels,  to  prevent  the 
escape  of  rats  by  swimming. 

In  inspecting  vessels  from  plague-infected  ports,  or  vessels  with  plague 
on  board  at  port  of  departure,  en  route  or  on  arrival,  the  personnel  of  the 
vessel  should  be  examined  with  special  reference  to  the  glandular  regions, 
cervical,  axillary,  and  inguinal,  and  for  such  examination  as  much  clothing 
should  be  removed  as  may  interfere  with  the  thoroughness  of  the  process. 
When  possible,  females  should  be  examined  by  female  inspectors. 

In  the  inspection  of  vessels  for  plague,  special  attention  must  be  directed 
to  the  discovery  of  cases  of  a  mild  type  or  of  the  pneumonic  form  of  the 
disease.  Suspected  or  doubtful  cases  should  be  subjected  to  bacteriologic 
examination  before  the  vessel  is  released. 


286  HYGIENE 

On  all  plague-infected  vessels  any  of  the  personnel  of  such  vessels  who, 
in  the  opinion  of  the  quarantine  officer,  are  infected  or  have  been  exposed  to 
infection,  shall  be  bathed  and  body,  clothing,  and  hand  baggage  disinfected. 

Nothing  shall  be  thrown  overboard  from  the  vessel,  not  even  deck  sweep- 
ings. Such  material  shall  be  burned  in  the  furnaces  of  a  steamer,  or  in  a 
place  specially  designated,  but  not  in  the  galley. 

Special  precautions  must  be  taken  against  rats,  mice,  ants,  flies,  fleas, 
and  other  animals,  on  account  of  the  danger  of  the  infection  of  the  disease 
being  spread  through  their  agency. 

As  soon  as  practicable,  there  shall  be  a  preliminary  disinfection  with 
sulphur  dioxide  for  the  purpose  of  killing  rats  and  vermin,  before  further  dis- 
infecting processes  are  applied  to  the  vessel  and  her  cargo.  The  killing  of 
any  escaping  rats  shall  be  provided  for  by  a  water  guard  in  small  boats,  and 
no  person  with  abrasions  or  open  sores  should  be  employed  in  the  handling  of 
the  vessel  or  her  cargo. 

The  vessel  shall  be  submitted  to  a  simultaneous  disinfection  in  all  parts 
with  sulphur  dioxide  to  insure  the  destruction  of  rats  and  vermin.  The  rats 
shall  be  subsequently  gathered  and  burned,  due  precautions  being  taken  not 
to  touch  them  with  the  bare  hands,  and  the  places  where  found  disinfected 
with  a  germicidal  solution;  and  the  quarantine  officer  shall  insure  himself 
that  the  vessel  is  free  of  rats  and  vermin  before  granting  free  pratique. 

Canadian  and  Mexican  Frontiers 

When  practicable,  alien  immigrants  arriving  at  Canadian  or  Mexican 
ports  destined  for  the  United  States  shall  be  inspected  at  the  Canadian  or 
Mexican  port  of  arrival  by  the  United  States  consular  or  medical  officer,  and 
be  subjected  to  the  same  sanitary  restrictions  as  are  called  for  by  the  rules  and 
regulations  governing  United  States  ports. 

Inspection  cards  will  be  issued  by  the  consular  or  United  States  medical 
officer  at  the  Canadian  or  Mexican  port  of  arrival  to  all  such  alien  immigrants, 
and  labels  affixed  to  their  baggage,  as  is  required  at  foreign  ports  in  the  case 
of  those  coming  direct  to  any  port  of  the  United  States. 

If  any  person  be  found  suffering  from  a  quarantinable  disease,  or  be 
presumably  infected,  he  shall  be  denied  entry  or  shall  be  kept  under  quaran- 
tine observation  so  long  as  danger  of  conveying  the  infection  exists. 

Any  baggage  or  other  effects  believed  to  be  infected  shall  be  refused  entry 
unless  disinfected  in  accordance  with  these  regulations. 

Persons  coming  from  localities  where  cholera  is  prevailing  shall  not  be 
allowed  entry  until  after  five  days  have  elapsed  since  last  presumable  exposure 
to  infection,  and  their  baggage  disinfected. 

During  the  quarantine  season  persons  not  positively  identified  as  immune 
to  yellow  fever,  coming  from  places  where  yellow  fever  prevails,  will  not  be 
permitted  to  enter  until  they  have  been  away  from  said  localities  five  full  days. 

Persons  coming  from  localities  where  smallpox  is  prevailing  shall  not  be 
allowed  entry  without  vaccination,  unless  they  are  protected  by  a  previous 
attack  of  the  disease  or  a  recent  successful  vaccination.  The  baggage  of 
persons  from  such  localities  shall  be  disinfected. 


QUARANTINE  287 

Persons  coming  from  localities  where  typhus  fever  prevails  in  epidemic 
form  shall  not  be  allowed  entry  until  twelve  days  have  elapsed  since  their  last 
possible  exposure  to  infection  and  the  disinfection  of  their  baggage. 

Persons  coming  from  localities  where  plague  is  prevailing  shall  not  be 
allowed  entry  until  seven  days  have  elapsed  since  their  last  possible  exposure 
to  infection  and  the  disinfection  of  their  baggage. 

No  common  carrier  which  is  infected,  or  suspected  of  being  infected,  shall 
be  allowed  to  enter  the  United  States  until  after  such  measures  have  been  taken 
as  will  render  it  safe. 

Articles  or  merchandise,  personal  effects,  etc.,  which  are  presumably 
infected,  shall  not  be  allowed  entry  into  the  United  States  until  after  dis- 
infection. 

Rags  gathered  and  baled  in  Canada,  accompanied  by  affidavits  that  the 
ports  or  places  where  collected  or  handled  were  free  from  quarantinable 
disease  for  thirty  days  prior  to  shipment,  may  be  admitted  to  entry;  but  rags 
from  foreign  ports  shipped  through  Canada  shall  not  be  admitted  to  entry 
unless  they  are  accompanied  by  a  certificate  of  a  United  States  consul  or 
medical  officer  of  the  United  States  that  they  have  been  disinfected,  or  until 
after  they  have  been  unbaled  and  disinfected  at  the  port  of  arrival. 

Where  not  otherwise  specifically  stated,  the  rules  and  regulations  for 
maritime  quarantine  shall  be  applied  at  stations  on  the  Canadian  and  Mexican 
frontiers;  and  the  methods  of  disinfections  shall  be  those  prescribed  in  these 
regulations. 

Application  of  Disinfectants  in  Quarantine  Work 

Holds  of  iron  vessels,  empty,  shall  be  disinfected  by  either: 

(a)  Sulphur  dioxide  generated  by  burning  sulphur  five  pounds  per  one 
thousand  cubic  feet  of  air  space,  or  liberated  from  ten  pounds  of  liquid  sulphur 
dioxide,  sufficient  moisture  being  present  in  both  cases;  time  of  exposure, 
twenty-four  hours: 

(b)  Washing  with  a  solution  of  bichloride  of  mercury,  1  :  1000. 
Holds  of  wooden  vessels,  empty,  shall  be  disinfected  by: 

(a)  Sulphur  dioxide  in  the  manner  prescribed  above,  followed  by 

(b)  Washing  with  a  solution  of  bichloride  of  mercury. 

In  the  case  of  all  vessels,  both  iron  and  wooden,  when  treated  for  yellow 
fever  or  plague  infection,  the  first  process  shall  be  a  preliminary  fumigation 
by  sulphur  dioxide  in  the  manner  previously  stated,  in  order  to  insure  the 
destruction  of  mosquitoes,  rats,  and  other  vermin. 

Holds  of  cargo  vessels,  when  cargo  cannot  be  removed,  shall  be  disin- 
fected in  so  far  as  possible  by  sulphur  dioxide  not  less  than  four  per  cent 
per  volume  strength,  and  where  possible  this  should  be  generated  from  a 
furnace  to  minimize  danger  of  fire  in  cargo: 

Living  apartments,  cabins,  and  forecastles  of  vessels  shall  be  disinfected 
by  one  or  more  of  the  following  methods : 

(a)  Sulphur  dioxide,  the  destructive  action  of  the  gas  on  property  being 
borne  in  mind. 

(b)  Formaldehyde  gas. 


288  HYGIENE 

(c)  Washing  with  solution  of  bichloride  of  mercury,  1:  1000,  or  five  per 
cent  solution  of  formaline,  or  five  per  cent  solution  of  carbolic  acid,  preference 
being  given  to  carbolic  acid  for  application  to  polished  v^oods,  bright  metals, 
and  other  objects  injured  by  metallic  salts. 

The  forecastle,  steerage,  and  other  living  apartments  in  bad  sanitary 
condition  must  be  disinfected  by  method  (a),  followed  by  method  (c). 

Mattresses,  pillows,  and  heavy  fabrics  are  to  be  disinfected  by: 

(a)  Boiling. 

(b)  Flowing  steam,  i.e.  steam  not  under  pressure. 

(c)  Steam  under  pressure. 

(d)  Steam  in  a  special  apparatus  with  vacuum  attachment. 

Clothing,  fabrics,  textiles,  curtains,  hangings,  etc.,  may  be  treated  by 
either  of  the  above  methods  from  (a)  to  (d)  inclusive,  as  circumstances  may 
demand,  or  by  formaldehyde  gas  or  sulphur  dioxide  where  the  article  is  of  a 
character  which  will  not  be  damaged  by  sulphur  dioxide. 

Articles  injured  by  steam,  such  as  leather,  furs,  skins,  rubber,  trunks, 
valises,  hats  and  caps,  bound  books,  silks,  and  fine  woolens  should  not  be  dis- 
infected by  steam.  Such  articles  should  be  disinfected  by  formaldehyde  gas 
or  by  any  of  the  agents  allowed  in  these  regulations  which  may  be  applicable 
thereto.  Those  which  will  be  injured  by  wetting  should  be  disinfected  by  a 
gaseous  agent. 

Clothing,  textile,  and  baggage,  clean  and  in  good  condition,  but  suspected 
of  infection,  can  be  efficiently  and  least  injuriously  disinfected  by  formalde- 
hyde gas. 

Textiles  which  are  soiled  with  the  discharges  of  the  sick  or  presumably 
are  deeply  infected,  must  be  disinfected  by: 

(a)  Boiling. 

(b)  Steam. 

(c)  Immersion  in  one  of  the  germicidal  solutions. 

Cooking  and  eating  utensils  are  always  to  be  disinfected  by  immersion 
in  boiling  water  or  by  steam. 

Interstate  Quarantine 

An  act  of  Congress,  passed  March  27,  1890,  provides  that  whenever  it 
shall  be  made  to  appear  to  the  satisfaction  of  the  President,  that  cholera, 
yellow  fever,  smallpox,  or  plague  exists  in  any  state  or  territory  or  in  the 
District  of  Columbia,  and  that  there  is  danger  of  the  spread  of  such  disease 
into  other  states,  territories,  or  the  District  of  Columbia,  he  is  hereby  author- 
ized to  cause  the  Secretary  of  the  Treasury  to  promulgate  such  rules  and 
regulations  as  in  his  judgment  may  be  necessary  to  prevent  the  spread  of  such 
disease  from  one  state  or  territory  into  another,  or  from  any  state  or  territory 
into  the  District  of  Columbia,  or  from  the  District  of  Columbia  into  any  state 
or  territory,  and  to  employ  such  regulations  to  prevent  the  spread  of  such 
disease.  The  said  rules  and  regulations  shall  be  prepared  by  the  supervising 
surgeon  general  of  the  Marine  Hospital  Service,  under  the  direction  of  the 
Secretary  of  the  Treasury. 

The  following  rules  and  regulations  have  been  made: 


QUARANTINE  289 

Interstate  Quarantine  Regulations 

Article  I 

Quarantinable  Diseases 

(1)  For  the  purposes  of  these  regulations  the  quarantineable  diseases  are 
cholera  (cholerine),  yellow  fever,  smallpox,  typhus  fever,  leprosy,  and  plague. 

Article  II 
Notification 

(1)  State  and  municipal  health  officers  should  immediately  notify  the 
supervising  surgeon  general  of  the  United  States  Marine  Hospital  Service  by 
telegraph  or  by  letter  of  the  existence  of  any  of  the  above-mentioned  quar- 
antinable diseases  in  their  respective  states  or  localities. 

Article  III 
General  Regulations 

(1)  Persons  suffering  from  a  quarantinable  disease  shall  be  isolated  until 
no  longer  capable  of  transmitting  the  disease  to  others.  Persons  exposed  to 
the  infection  of  a  quarantinable  disease  shall  be  isolated,  under  observation, 
for  such  a  period  of  time  as  may  be  necessary  to  demonstrate  their  freedom 
from  the  disease. 

All  articles  pertaining  to  such  persons,  liable  to  convey  infection,  shall  be 
disinfected  as  hereinafter  provided. 

(2)  The  apartments  occupied  by  persons  suffering  from  quarantinable 
disease,  and  adjoining  apartments  when  deemed  infected,  together  with 
articles  therein,  shall  be  disinfected  upon  the  termination  of  the  disease. 

(3)  Communication  shall  not  be  held  with  the  above-named  persons  and 
apartments,  except  under  the  direction  of  a  duly  qualified  officer. 

(4)  All  cases  of  quarantinable  disease,  and  all  cases  suspected  of  belong- 
ing to  this  class,  shall  be  at  once  reported  by  the  physician  in  attendance  to  the 
proper  authorities. 

(5)  No  common  carrier  shall  accept  for  transportation  any  person  suffer- 
ing with  a  quarantinable  disease,  nor  any  infected  article  of  clothing,  bedding, 
or  personal  property. 

The  body  of  any  person  who  has  died  of  a  quarantinable  disease  shall 
not  be  transported,  save  in  hermetically  sealed  coffins,  and  by  order  of  the 
state  or  local  health  officer. 

(6)  In  the  event  of  the  prevalence  of  smallpox,  all  persons  exposed  to  the 
infection,  who  are  not  protected  by  vaccination  or  a  previous  attack  of  the 
disease,  shall  be  at  once  vaccinated  or  isolated  for  a  period  of  fourteen  days. 

(7)  During  the  prevalence  of  cholera  all  the  dejecta  of  cholera  patients 
shall  be  at  once  disinfected  as  hereinafter  provided,  to  prevent  possible  con- 
tamination of  the  food  and  water  supply. 


290  HYGIENE 

Article  IV 

Yellow  Fever 

In  addition  to  the  foregoing  regulations  contained  in  Article  III  the  fol- 
lowing special  provisions  are  made  with  regard  to  the  prevention  of  the  intro- 
duction and  spread  of  yellow  fever: 

(1)  Localities  infected  with  yellow  fever,  and  localities  contiguous  thereto, 
should  be  depopulated  as  rapidly  and  as  completely  as  possible,  so  far  as  the 
same  can  be  safely  done;  persons  from  non-infected  localities  and  who  have 
not  been  exposed  to  infection  being  allowed  to  leave  without  detention. 
Those  who  have  been  exposed,  or  who  come  from  infected  localities,  shall  be 
required  to  undergo  a  period  of  detention  and  observation  of  ten  days  from 
the  date  of  last  exposure  in  a  camp  of  probation  or  other  designated  place. 

Clothing  and  other  articles  capable  of  conveying  infection  shall  not  be 
transported  to  non-infected  localities  without  disinfection. 

(2)  Persons  who  have  been  exposed  may  be  permitted  to  proceed  without 
detention  to  localities  incapable  of  becoming  infected  and  whose  authorities 
are  willing  to  receive  them,  and  after  arrangements  have  been  perfected  to 
the  satisfaction  of  the  proper  health  officer,  for  the  detention  in  said  localities 
for  a  period  often  days. 

(3)  The  suspects  who  are  isolated  under  the  provisions  of  paragraph  1, 
Article  III,  shall  be  kept  free  from  all  possibility  of  infection. 

(4)  So  far  as  possible,  the  sick  should  be  removed  to  a  central  location 
for  treatment. 

(5)  Buildings  in  which  yellow  fever  has  occurred  and  localities  believed 
to  be  infected  with  said  disease  must  be  disinfected  as  thoroughly  as  possible. 

(6)  As  soon  as  the  disease  becomes  epidemic  the  railroad  trains  carrying 
persons  allowed  to  depart  from  a  city  or  place  infected  with  yellow  fever  shall 
be  under  medical  supervision. 

(7)  Common  carriers  from  the  infected  districts,  or  believed  to  be  carry- 
ing persons  and  effects  capable  of  conveying  infection,  shall  be  subject  to  a 
sanitary  inspection,  and  such  persons  and  effects  shall  not  be  allowed  to  pro- 
ceed, except  as  provided  for  by  paragraph  2. 

(8)  At  the  close  of  an  epidemic  the  houses  where  sickness  has  occurred, 
and  the  contents  of  the  same,  and  houses  and  contents  that  are  presumably 
infected,  shall  be  disinfected  as  hereinafter  prescribed. 

Special  Regulations  to  Prevent  the  Spread  of  Plague  in  the  United 

States 

During  the  existence  of  plague  at  any  point  in  the  United  States  the 
surgeon  general  of  the  Marine  Hospital  Service  is  authorized  to  forbid  the 
sale  or  donation  of  transporation  by  common  carrier  to  Asiatics  or  other  races 
particularly  liable  to  the  disease. 

No  common  carrier  shall  accept  for  transportation  any  person  suffering 
with  plague  or  any  article  infected    therewith,  nor  shall  common  carriers 


QUARANTINE  291 

accept  for  transportation  any  class  of  persons  who  may  be  designated  by  the 
surgeon  general  of  the  Marine  Hospital  Service  as  being  likely  to  convey  the 
risk  of  plague  contagion  to  other  communities,  and  said  common  carriers  shall 
be  subject  to  inspection. 

The  body  of  any  person  w^ho  has  died  of  plague  shall  not  be  transported 
except  in  a  hermetically  sealed  coffin  and  by  consent  of  the  local  health 
officer,  in  addition  to  the  local  representatives  of  the  Marine  Hospital  Service. 
Wherever  possible,  such  bodies  should  be  cremated. 

Maritime  Quarantine  Maintained  by  States  Bordering  on  the 
Atlantic  and  Pacific  Oceans,  the  Gulf  of  Mexico,  the  Mississippi 
and  Ohio  Rivers,  and  the  Great  Lakes 

The  national  government  has  taken  over  the  regulation  of  foreign  inter- 
course at  most  of  the  ports  of  entry,  especially  along  the  southern  borders 
where  there  is  danger  of  the  importation  of  yellow  fever,  though  at  several 
important  ports  the  local  authorities  still  exercise  the  quarantine  function 
under  the  supervision  of  the  United  States  Marine  Hospital  Service,  notably 
at  Boston,  New  York,  and  Baltimore.  Although  until  recently  the  state  of 
Louisiana  maintained  four  quarantine  stations  on  the  lower  portion  of  the 
Mississippi  River,  these  stations  have  now  been  given  over  to  the  complete 
control  of  the  United  States. 

The  following  states  still  maintain  inspection  and  quarantine  at  ports 
of  entry: 

California,  Connecticut,  Delaware,  Georgia,  Indiana,  Kentucky,  Maine, 
Maryland,  Massachusetts,  Michigan,  New  Hampshire,  New  Jersey,  New 
York,  Ohio,  Oregon,  Pennsylvania,  and  Texas. 

Inland  Quarantine 

Inland  quarantine,  or  the  application  of  quarantine  measures  by  state 
and  local  boards  of  health  to  inland  territory,  especially  the  maintenance  of 
quarantine  by  one  state  against  neighboring  states,  is  provided  for  in  the 
laws  of  the  following  states:  California,  Connecticut,  Georgia,  Indiana, 
Illinois,  Kansas,  Kentucky,  Louisiana,  Maine,  Maryland,  Massachusetts, 
Michigan,  Minnesota,  Mississippi,  Missouri,  Nebraska,  New  Hampshire, 
New  Jersey,  New  Mexico,  North  Carolina,  Ohio,  Oklahoma,  Oregon,  Penn- 
sylvania, Tennessee,  Virginia,  West  Virginia,  and  Wyoming. 

Distrirution  of  Quarantine  Powers  in  the  Various  States 

The  administration  of  public  health  affairs  in  cities,  towns,  and  in  the 
rural  districts  in  the  various  states  differs  broadly;  no  two  states  agreeing 
altogether  in  the  manner  in  which  quarantine  powers  are  distributed. 

In  some  of  the  states  the  power  of  enforcing  quarantine  is  largely  or 
wholly  centralized  in  the  state  board  of  health,  the  local  authorities  being 
merely  the  agents  of  the  state  board.  The  following  states  belong  in  this 
class:  Kansas,  Louisiana,  Mississippi,  New  Mexico,  South  Carolina,  Ten- 
nessee, Texas,  Vermont,  Washington,  Wyoming  (absolute). 


292  HYGIENE 

In  most  of  the  states  the  quarantine  powers  are  conferred  upon  the  local 
health  authorities,  usually  with  the  proviso  that  the  rules  and  regulations 
promulgated  by  the  state  board  of  health  be  observed  in  the  administration 
of  public  health  affairs;  the  state  boards  in  most  instances  having  the  power 
to  supersede  the  local  authorities,  and  to  assume  full  control  of  affairs  in 
case  the  regulations  are  not  properly  carried  into  effect:  Arizona,  California, 
Connecticut,  Delaware,  Illinois,  Indiana,  Iowa,  Kentucky,  Maine,  Mary- 
land, Massachusetts,  Michigan,  Minnesota,  Missouri,  Montana,  Nebraska, 
New  Jersey,  New  York,  North  Carolina,  North  Dakota,  Ohio,  Oklahoma, 
Oregon,  Pennsylvania,  South  Carolina,  Utah,  Vermont,  Virginia,  Washing- 
ton, West  Virginia,  and  Wisconsin. 

In  some  of  the  states  the  local  health  authorities  have  an  almost  inde- 
pendent existence  and  have  the  quarantine  powers  conferred  upon  them. 
This  is  true  in  more  or  less  degree  of  the  following  state  laws :  Colorado, 
Georgia,  New  Hampshire,  and  North  Carolina.  It  is  difficult  to  satisfac- 
torily classify  several  of  the  states  in  this  respect. 

The  following  states  have  county  boards  of  health,  besides  the  local 
boards  of  health  of  cities  and  towns,  to  v/hich  are  delegated  the  power  of 
administering  quarantine  regulations:  Arizona,  California,  Colorado,  Con- 
necticut, Georgia,  Illinois,  Indiana,  Kansas,  Kentucky,  Louisiana,  Miss- 
issippi, Missouri,  North  Carolina,  Oklahoma,  Oregon,  Tennessee,  Utah, 
Virginia,  West  Virginia. 

The  following  states  have  township  boards  of  health  in  addition  to  the 
boards  of  health  of  cities  and  to  which  is  delegated  the  power  of  enforcing 
quarantine  in  the  rural  districts:  Illinois,  Iowa,  Michigan,  Minnesota,  New 
Jersey,  Oklahoma,  and  Pennsylvania. 

The  following  states  have  local  boards  of  health  in  incorporated  cities 
and  towns  whose  duty  it  is  to  administer  the  public  affairs  of  the  municipality: 
Arizona,  California,  Colorado,  Connecticut,  Delaware,  Georgia,  Illinois, 
Indiana,  Iowa,  Kansas,  Kentucky,  Louisiana,  Maine,  Maryland,  Massa- 
chusetts, Michigan,  Minnesota,  Mississippi,  Missouri,  Montana,  Nebraska, 
New  Hampshire,  New  Jersey,  New  York,  Ohio,  Oklahoma,  Oregon,  Penn- 
sylvania, South  Carolina,  Tennessee,  Texas,  Utah,  Vermont,  Virginia, 
Washington,  and  West  Virginia. 

The  following  states  have  the  power  of  inspecting  and  isolating  infected 
persons  and  merchandise  in  transit  to  or  through  the  state  on  public  con- 
veyances: Connecticut,  Georgia,  Illinois,  Kansas,  Kentucky,  Louisiana, 
Maine,  Maryland,  Michigan,  Mississippi,  New  Hampshire,  New  Mexico, 
Ohio,  Oklahoma,  Pennsylvania,  Tennessee,  Virginia,  and  Wyoming. 

Disease  against  which  Quarantine  is  Imposed 

All  the  states  whose  laws  I  have  been  able  to  examine,  impose  quarantine 
against  smallpox,  scarlet  fever,  and  diphtheria,  except  in  Arizona,  where  no 
diseases  are  specified,  and  in  New  Mexico  and  West  Virginia,  where  small- 
pox is  the  one  disease  specified. 


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QUARANTINE  293 

The  following  states  quarantine  against  Asiatic  cholera:  California, 
Connecticut,  Delaware,  Georgia,  Illinois,  Indiana,  Iowa,  Kansas,  Kentucky, 
Louisiana,  Maine,  Maryland,  Michigan,  Mississippi,  Missouri,  Nebraska, 
New  Hampshire,  New  Jersey,  New  York,  North  Carolina,  Ohio,  Oklahoma, 
Oregon,  Pennsylvania,  Tennessee,  Texas,  Vermont,  Virginia,  Washington, 
Wisconsin,  and  Wyoming. 

The  following  states  quarantine  against  yellow  fever:  CaUfornia,  Con- 
necticut, Delaware,  Georgia,  Illinois,  Indiana,  Kentucky,  Louisiana,  Miss- 
issippi, Missouri,  Nebraska,  New  Jersey,  New  York,  North  Carolina,  Ohio, 
Oregon,  Pennsylvania,  Tennessee,  Texas,  Vermont,  Virginia,  Washington, 
Wisconsin,  and  Wyoming. 

The  following  states  quarantine  against  typhus  fever:  California, 
Delaware,  Georgia,  Indiana,  Louisiana,  Maine,  Missouri,  Nebraska,  New 
Jersey,  New  York,  North  Carolina,  Ohio,  Oregon,  Pennsylvania,  Texas, 
Vermont,  Virginia,  Washington,  Wisconsin,  and  Wyoming. 

The  following  states  quarantine  against  bubonic  plague:  California, 
Delaware,  Indiana,  Iowa,  Louisiana,  Maine,  Missouri,  New  Jersey,  Ohio, 
Oklahoma,  Oregon,  Pennsylvania,  Texas,  Virginia,  Washington,  Wisconsin, 
and  Wyoming. 

The  following  states  quarantine  against  measles:  California,  Indiana, 
Iowa  (placard),  Kentucky,  Louisiana,  Maryland,  Minnesota,  Missouri, 
Montana,  New  Hampshire  (reportable),  New  York,  North  Dakota,  Ohio 
(optional),  Oklahoma,  Pennsylvania,  Tennessee,  Utah,  Vermont  (modified), 
Wisconsin,  and  Wyoming  (modified). 

The  following  states  require  all  cases  of  typhoid  fever  to  be  reported : 
California,  Illinois,  Indiana,  Iowa,  Louisiana,  Minnesota,  Nebraska,  New 
Hampshire,  New  Jersey,  New  York,  Ohio,  Pennsylvania,  Tennessee,  Texas, 
Vermont,  and  Washington. 

The  following  states  quarantine  against  leprosy:  California,  Indiana, 
Iowa,  Louisiana,  Missouri,  Nebraska,  New  Jersey,  Oklahoma,  Pennsylvania, 
Texas,  Washington,  and  Wyoming. 

The  following  states  quarantine  cases  of  epidemic  cerebro-spinal  menm- 
gitis  :  California  (reportable),  Iowa,  Kansas,  Louisiana,  Minnesota,  Nebraska, 
New  York,  Oklahoma,  Pennsylvania,  Tennessee,  Texas,  Vermont,  Wiscon- 
sin, and  Wyoming  (modified). 

The  following  states  require  all  cases  of  tuberculosis  (pulmonary),  to 
be  reported:  California,  Indiana,  Iowa,  Louisiana,  Minnesota,  Nebraska, 
New  Hampshire,  New  York,  Pennsylvania,  Texas,  and  Vermont. 

The  following  states  require  notification  or  quarantine  of  all  cases  of 
whooping  cough:  California  (reportable),  Indiana,  Iowa  (placard),  Mary- 
land, Missouri,  Nebraska  (placard).  North  Dakota,  Ohio  (optional),  Okla- 
homa (placard),  Pennsylvania  (modified),  Tennessee,  Utah,  Vermont  (modi- 
fied), Wisconsin,  and  Wyoming  (modified). 

The  following  states  require  all  cases  of  mumps  to  be  reported :  Cali- 
fornia, Iowa  (placard),  Maryland,  Oklahoma  (placard),  Pennsylvania,  Ten- 
nessee, and  Vermont  (modified). 

The  following  states  require  all  cases  of  chickenpox  to  be  reported: 


294  HYGIENE 

California,  Indiana,  Iowa  (placard),  Nebraska  (placard),  Maryland,  Ohio 
(optional),  Oklahoma  (placard),  Pennsylvania,  Tennessee,  and  Vermont 
(modified  quarantine). 

The  following  states  require  all  cases  of  German  measles  to  be  reported: 
Pennsylvania  (modified  quarantine),  Tennessee,  Vermont  (modified  quar- 
antine). 

The  following  states  require  all  cases  of  epidemic  dysentery  to  be  re- 
ported: California,  Louisiana,  Pennsylvania,  and  Texas. 

The  following  states  require  cases  of  dengue  to  be  reported:  California, 
Louisiana,  Mississippi,  and  Texas. 

The  following  states  require  the  reporting  and  quarantining  of  cases  of 
membranous  croup:  CaHfornia,  Delaware,  Georgia,  Iowa,  Kentucky, 
Missouri,  New  Hampshire,  New  Jersey,  Ohio,  Oklahoma,  Oregon,  Penn- 
sylvania, Vermont,  Wisconsin,  and  Wyoming. 

The  following  states  require  all  cases  of  anthrax  to  be  reported :  Cali- 
fornia, Louisiana,  Pennsylvania,  and  Texas. 

The  following  require  the  reporting  of  glanders:  California,  Louisiana, 
and  Pennsylvania. 

The  following  require  the  reporting  of  cases  of  pneumonia:  California, 
Iowa,  Louisiana,  and  Pennsylvania. 

In  addition  to  the  foregoing,  the  following  diseases  must  be  reported  in 
different  states:  Tetanus  and  trachoma  in  Pennsylvania  and  California. 
Trichinosis  in  Pennsylvania  and  New  Jersey.  Relapsing  fever  in  Pennsyl- 
vania and  Louisiana.  Puerpural  fever  in  Pennsylvania,  Nebraska,  and 
Iowa,  Actinomycosis  in  Pennsylvania.  Hydrophobia  in  Louisiana.  Oph- 
thalmia neonatorum  in  Nebraska  and  New  York.  Uncinariasis  in  Cali- 
fornia. Erysipelas  in  Pennsylvania.  Cuban  or  Manilla  itch  in  Pennsyl- 
vania and  California.     Anterior  poliomyelitis  in  Minnesota. 


Chapter  XV 
INFECTIOUS  DISEASES* 

Introductory  remarks  —  Tables  giving  incubation,  mode  of  onset,  occurrence  of 
eruption,  character  of  eruption,  fading  or  disappearance  of  eruption,  duration  of 
illness,  character  of  other  symptoms  and  phenomena,  mode  of  contagion  and  period 
of  contagion  —  Methods  in  use  by  physicians  to  protect  themselves,  their  families, 
and  their  patients. 

THE  tables  and  other  forms  of  data  herein  are  based  upon  the  recorded 
opinions  of  the  leading  authorities,  and  are  as  accurate  as  the  circum- 
stances render  possible.  But  it  must  not  be  forgotten  that  there 
is  oftimes  a  wide  variation  in  opinion,  and  that  disease  expression  varies 
in  different  epidemics.  Therefore  the  data  cannot  be  aught  but  compara- 
tive and  suggestive.  Very  naturally  various  state  boards  of  health  lay  down 
differing  standards  and  the  present  writer  does  not  know  of  any  better  way  at 
present  than  for  physicians  to  be  guided  by  the  instructions  issued  by  the  au- 
thorities in  his  own  state.  Various  diseases  of  animals  communicable  to  man 
are  omitted  here  because  considered  under  a  special  heading  in  the  appendix. 


Period  of  Incubation 
Mode  of  Onset 

Time  of  Eruption 

Character  Eruption 


Disappearance  of  Eruption 
Duration  of  illness 

Character  other  Symptoms 


Mode  of  contagion 


Period  of  Contagion 


Bubonic  Plague 

Average,  three  to  four  days.  Certain  individ- 
ual cases,  six  to  eight  days,  (Greisinger.) 
Usually  sudden  with  severe  chiU  and  fever 
and  soon  followed  by  severe  systematic  intoxi- 
cation due  to  the  plague  bacteria. 
No  characteristic  eruption.  In  certain  cases, 
hemorrhages  in  skin  and  mucous  membranes 
first  week  of  disease. 

When  present,  small  hemorrhages  as  above, 
especially  digestive,  bronchial,  and  urethral 
tracts. 

No  regular  course. 

Five  to  thirty  days.  Cases  longer  usually  fatal 
and  due  to  mixed  infection,  staph,  c-strep.  c. 
Enlargement  lymph  glands  in  inguinal,  axil- 
lary, and  popliteal  regions  and  elsewhere. 
Often  suppurate.  Symp.  cardiac  poison  from 
toxins. 

From  bronchial  secretions,  pus  from  buboes, 
carriers     usual   ones,    and    rats,    mice,    fleas, 
ground  squirrels,  and  possibly  other  vermin. 
Ten  days  after  the  cessation  of  all  symptoms. 
(International  Sanitary  Conference  at  Venice.) 


*By  Harvey  F.  Smith,  Ph.B.,  M.D. 


296 


HYGIENE 


Period  of  Incubation 
Mode  of  Onset 

Time  of  Eruption 
Character  of  Eruption 


Disappearance  of  Eruption 
Duration  of  Illness 


Other  Symptoms 
Mode  of  Contagion 


Period  of  Contagion 
Note 


Period  Incubation 
Mode  of  Onset 

Time  of  Eruption 
Character  of  Eruption 


Disappearance  of  Eruption 

Duration  Illness 
Other  Symptoms 

Mode  of  Contagion 


Period  of  Contagion 


Cerebro-spinal  Meningitis 

Not  definitely  known.  Probably  three  or  four 
days. 

No  prodromal  symptom.  Repeated  chiUs, 
vomiting,  and  severe  pain  in  head  and  back 
usher  in  disease. 

Irregular.  Herpes  labialis  frequently  appear 
between  third  and  sixth  days. 
No  characteristic  eruption.  Herpes  facialis 
in  many  cases.  Frequently  vaso-motor  dis- 
turbances cause  an  erythema  of  skin  or  a  pur- 
puric rash. 

No  regular  time  or  manner. 
Death  in  from  fifty  to  eighty  per  cent  of  cases, 
in  from  eight  hours  to  two  weeks.      In  case  of 
recovery,  convalescence  is  very  prolonged. 
Marked  rigidity  muscles  back  and  neck, inflam- 
matory exudate  causes  various  pressure  symp- 
toms; cranial  and  spinal  nerves  involved. 
From  the  patient  and  especially  the  bronchial 
and  nasal  secretions,  infected    clothing    and 
other  articles,  from  a  third  person. 
During  entire  illness. 

The  epidemic  form  of  this  disease  has  not  oc- 
curred in  every  section  of  this  country  and 
some  physicians  have  never  seen  a  case.  Per- 
mit me  to  sound  a  note  of  special  warning  re- 
garding this  quickly  fatal  disease. 

Chickenpox 

Usually  ten  to  fourteen  days. 

Slight  fever,  vesicular  eruption.    Vomiting  and 

convulsions  in  severe  cases. 
Appears  within  first  twenty-four  hours. 
Discrete,  superficial,  umbilicated  vesicles.    Ap- 
pear in  crops  three  to  five  days.     Later,  con- 
tents vesicles  become  milky  and  sero-purulent. 

Brown  crusts  form  on  vesicles,  which  fall  off  in 

one  week.  Seldom  scars ;  perhaps  two  or  three. 

Usually  one  to  two  weeks. 

Very  moderate  fever  two  to  four  days.      No 

constitutional  symptoms  of  any  moment. 
From  exfoliation  of  crusts  on  body  and  pos- 
sibly from  respiratory  passages.     Direct  con- 
tact not  necessary. 

Until  last  crusts  are  off. 


INFECTIOUS  DISEASES 


297 


Cholera  (Asiatic) 


Period  of  Incubation 
Mode  of  Onset 


Eruption 
Duration  lUness 


Other  Symptom? 


Mode  of  Contagion 


Period  of  Contagion 


A  few  hours  to  five  days. 

Mild  cases  (Cholerine)  diarrhoea  ten  to  twenty 
stools  per  day.  Vomiting  —  muscular  and  ab- 
dominal cramps.  Cholera  gravis  —  develop- 
ment more  rapid,  greater  prostration,  tem- 
perature subnormal. 
None. 

Death  may  occur  several  hours  after  onset. 
Mild  cases  recover  one  to  two  weeks.  Con- 
valescence may  be  four  months. 
Spas,  contrac.  muscles  calves  —  distorted 
facial  expression  —  cyanosis  —  sunken  eyes  — 
Stools  are  large,  watery,  painless,  frequent  (so 
called  rice  water)  —  persistent  vomiting  — 
—  secondary  infection  common. 
Caused  by  a  variety  of  comma  b.  propagated 
chiefly  by  contaminated  water.  Carried  by 
water  and  culinary  articles,  foods,  travelers,  etc. 
Hard  to  define.  United  States  navy  requires 
bacteriological  examination  in  some  cases. 
Health  officers  rely  largely  upon  freedom  from 
diarrhoea.     Bacilli  may  live  long  time. 


Diphtheria 


Period  of  Incubation 
Mode  of  Onset 

Eruption     ' 
Duration  of  Illness 


Other  Symptoms 


Period  of  Contagion 


Mode  of  Contagion 


Average  from  two  to  eight  days. 
Chill,   malaise,   moderate   fever,    painful  and 
difficult  deglutition,  red  and  congested  fauces. 
None. 

Indefinite;  depends  upon  type  of  infection  and 
use   or   neglect  of  serum  therapy.     If  used 
within  first  thirty-six  hours  in  adequate  dose, 
recovery  may  occur  as  early  as  three  days. 
The  gray-white  membrane  on  fauces  within 
first  twenty-four  hours,   enlargement  of  the 
lymph  glands  under  angle  of  jaw;   heart,  kid- 
ney, and  nerve  complications. 
From  beginning  of  symptoms  until  two  weeks 
after  all  membrane  has   disappeared.     Some 
persons  carry  the  germs  in  throat  for  an  inde- 
terminate  period,   except  that  swab  cultures 
may  determine  freedom  therefrom. 
From  person  to  person;  indirectly  from  third 
person;  from  infected  fomites  for  long  period. 


298 


HYGIENE 


Erysipelas 


Period  of  Incubation 
Mode  of  Onset 

Time  of  Eruption 
Character  of  Eruption 


Disappearance  of  Eruption 

Duration  of  Illness 
Other  Symptoms 


Mode  of  Contagion 
Period  of  Contagion 


Period  of  Incubation 
Mode  of  Onset 

Time  of  Eruption 
Character  of  Eruption 


Disappearance  of  Eruption 


Duration  of  Illness 
Other  Symptoms 

Mode  of  Contagion 
Period  of  Contagion 


Period  of  Incubation 
Mode  of  Onset 

Eruption 


From  fifteen  hours  to  three  days. 
Chill,   fever,   red    and    painful   spot   on    part 
affected,  commonly  the  nose. 
Within  first  twenty-four  hours. 
Bright  red,  swollen,  indurated,  sharply  circum- 
scribed; spreading  by  irregular  continuity;  in 
severe  cases  covered  with  vesicles,  pustules, 
or  crusts. 

Begins  in  three  to  five  days,  gradually  losing 
redness  and  swelling;  vesicles,  etc.,  dry  and 
scale. 

Simple,  eight  to  nine  days;  severe  and  ambu- 
latory, two  weeks  to  two  months. 
Depend  upon  the  point  of  entrance  of  the  strep- 
tococci and  resisting  power  of  individual  at 
time.  Relapses  a  common  phenomenon. 
From  patient,  third  person,  or  infected  objects. 
From  time  of  onset  until  all  symptoms  dis- 
appear. 

German  Measles 

Seventeen  to  twenty-one  days. 
Except  slight  fever,  prodromal  symptoms  ab- 
sent. 

First  day. 

Begins  upon  face,  spreads  rapidly  over  entire 
body,  varies  in  color  from  a  very  bright  red  to 
pale  red,  is  usually  macular. 
Disappears  rapidly.  Usually  the  face  is  clear 
by  time  extremities  are  involved.  Slight 
desquamation. 
Three  to  five  days. 

Moderate  enlargement  of  the  superficial  cervi- 
cal lymph  glands. 

Person  to  person,  infected  articles. 

From  onset  to  cessation  of  desquamation. 

Malarial  Fever 

About  fourteen  days,  varying  somewhat  with 

organism  and  Its  habitat. 

Sensation   of  lassitude,  headache,   feeling  of 

chilliness   increasing  to  a  typical  chill,  tem- 

perature  then  rises  abruptly  to  104  to  105°  F. 

Varies  according  to  climate,  type,  etc. 

None. 


INFECTIOUS  DISEASES 


299 


Duration  of  Illness 
Other  Symptoms 

Mode  of  Contagion. 
Period  of  Contagion 


Depends  upon  treatment  and  environment. 
May  last  for  months.  Chron.  mal.  tox.  lasts 
several  years. 

Vary  widely  with  stage  of  disease  and  variety 
of  infection.  Cerebral  and  nervous  symptoms 
are  common  in  severe  forms.  Congestive 
chill  may  be  quickly  fatal. 
From  the  anopheles  species  of  mosquito.  In 
the  Phihppines  there  is  said  to  be  a  species  of 
salt-water  mosquito  that  carries  infection. 
All  seasons  of  year,  especially  spring  and 
summer. 


Period  of  Incubation 
Mode  of  Onset 

Time  of  Eruption 
Character  of  Eruption 


Disappearance  Eruption 

Duration  of  Illness 
Other  Symptoms 
Mode  of  Contagion 
Period  of  Contagion 


Period  of  Incubation 
Mode  of  Onset 

Eruption 

Duration  of  Illness 
Other  Symptoms 

Mode  of  Contagion 

Period  of  Contagion 


Measles 

Nine  to  eleven  days. 

Fever,  coryza,  catarrhal  condition  conjunctiva 
and  upper  bronchial  tubes. 
Fourth  day. 

First    on    face;    spreads    rapidly   over    body. 
Small  bluish-red  slightly  raised   macules  ar- 
ranged in  crescentric  groups. 
Fading  begins  in  three  to  five  days.     Desqua- 
mates in  small  flakes. 
Average,  twelve  to  fourteen  days. 
Koplik's  spots,  marked  respiratory  catarrh. 
Contact  with  previous  case. 
From  onset  to  cessation  desquamation.     Pro- 
dromal stage  very  infectious. 

Mumps 

From  two  to  three  weeks. 

Mild    constitutional    symptoms  two  or  three 
days,  gradual  swelling  parotid  glands. 
None. 

Ordinarily  eight  to  fourteen  days. 
Parotid  swollen  and  painful  three  to  five  days. 
Orchitis  most  frequent  complication. 
Usually  from  person  to  person;  may  be  car- 
ried by  third  person  and  fomites. 
Begins  even  before  glandular  enlargement  and 
lasts    through    convalescence     (Falkenheim). 
Where  orchitis  exists,  it  is  diflRcult  to  say  when 
period  ends,  as  has  thus  far  not  been  definitely 
determined. 


300 


HYGIENE 


Pneumonia  (True) 


Period  of  Incubation 
Mode  of  Onset 

Eruption 
Duration  of  Illness 

Other  Symptoms 


Mode  of  Contagion 


Period  of  Incubation 


Mode  of  Onset 


Eruption 
Duration  of  lUness 

Other  Symptoms 


Mode  of  Contagion 


Period  of  Contagion 
Notes 


Period  of  Incubation 
Mode  of  Onset 

Time  of  Eruption 


Not  known,  probably  very  short. 
Severe  chill,  often  lasting  several  hours,  sharp 
chest  pains,  rapid  rise  of  temperature  (104-5). 
None. 

Typical  variety  at  least  ten  days,  but  range  is 
from  one  to  four  vi^eeks. 
Dyspnea,  rapid  respiration,  cough  and  "rusty" 
sputum,  flushed  face,  cyanosed  lips,  delirium, 
labored  heart  action. 

Not  definitely  known  — ■  diplococcus  pneu- 
monia of  Frankel  accepted  by  most  investi- 
gators. It  lives  normally  in  oral  cavity.  Ex- 
posure to  cold  or  trauma  probably  active  ex- 
citing causes. 

Puerperal  Fever 

Cannot  be  stated.  Depends  upon  the  infec- 
tive agent.  May  be  streptococci,  staphy- 
lococci, gonococci,  bac.  coli  com.,  or  one  of 
many  others. 

Varies  widely  from  the  sudden  eclamptic  con- 
vulsion to  a  relighted  pelvic  cellulitis.       Usu- 
ally symptoms  of  a  septic  fever. 
No  characteristic  eruption. 
From  few  hours  to  several  weeks.     Compli- 
cations may  prolong  case  for  months. 
Septic  endometritis,  vaginitis,  metritis,  metro- 
lymphangitis, salpingitis,  peritonitis,  pyemia, 
phlegmasia  alba  dolens,  etc. 
Unclean  midwifery,  other  infections,  such  as 
erysipelas  carried  by  medical  attendant;  from 
diphtheria,  scarlet  fever,  or  other  contagion  to 
which  woman  is  exposed,  occasionally  infec- 
tion through  air,  etc. 
Varies. 

Pennsylvania  requires  reporting  of  cases  of 
"  Puerperal  Fever,"  but  the  term  is  really 
hard  to  definitely  define,  since  so  many  infec- 
tions are  so  known.     See  the  text-books. 

Scarlet  Fever 

One  to  seven  days. 

ChiU,  fever,  vomiting,  sore  throat,  rapid  pulse, 

sometimes  convulsions. 

Second  day. 


INFECTIOUS  DISEASES 


301 


Character  of  Eruption 

Disappearance  of  Eruption 
Duration  of  Illness 

Other  Symptoms 


Mode  of  Contagion 
Period  of  Contagion 


Period  of  Incubation 
Mode  of  Onset 
Time  of  Eruption 
Character  of  Eruption 


Disappearance  of  Eruption 


Duration  of  lUness 
Other  Symptoms 


Mode  of  Contagion 
Period  of  Contagion 

Period  of  Incubation 

Mode  of  Onset 

Eruption 

Duration  of  Illness 
Other  Symptoms 


A  deep  red,  punctiform  rash,  uniform,  begin- 
ning on  face  and  neck,  spreading  rapidly  over 
body. 

At  end  of  third  or  fourth  day  rash  begins  to 
fade,  followed  by  scaly  desquamation. 
Varies  with  character  of  infection,  usually  ten 
to    fifteen    days.     Desquamation    sometimes 
continues  for  many  weeks. 
Pharyngitis,  follicular  tonsillitis,  enlarged  cer- 
vica     glands,   "  Strawberry  tongue,"   nephri- 
tis, otitis  media,  lymph,   suppurations. 
From  previous  case,  infected  fomites  or  milk. 
Onset  to  end  desquamation. 

Smallpox 

About  twelve  days. 

Fever,  chill,  vomiting,  pain  in  head  and  back. 
Third  or  fourth  day. 

Small  red  papules  on  face,  hands,  forearms, 
neck,  and  trunk,  and  increasing  in  numbers. 
They  become  vesicles  and  (three  days  later) 
pustules.  Where  close  together  they  coalesce 
and  skin  edematous. 

In  three  or  four  days  pustules  dry  up,  crusts 
form,  produce  odor,  fall  off  in  one  week,  leav- 
ing scar. 

Four  to  six  weeks. 

Secondary  fever  ten  days  after  primary  symp- 
toms. Severity  varies,  depending  upon  infec- 
tion and  number  of  pustules.  Many  compli- 
cations. 

From  patient,  infected  fomites,  flies.     The  in- 
fectious agent  very  tenacious  and  may  be  car- 
ried long  distances.     Third  parties  carry. 
From  onset  until  after  the  last  scab  has  been 
removed. 

Tetanus 

Two  thirds  of  aU  cases  develop  during  the 
second  or  third  week  following  infection. 
Begins  with  stiffness  of  muscles  of  mastication 
and  of  the  neck. 
None. 

From  a  few  days  to  several  weeks. 
General  muscular  rigidity,  opisthotonos,  tris- 
mus, risus  sardonicus,  extreme  hyperaesthesia, 
mind  is  clear. 


302 


HYGIENE 


Mode  of  contagion 

Period  of  Incubation 
Mode  of  Onset 


Time  of  Eruption 
Character  of  Eruption 


Disappearance  of  Eruption 
Duration  of  Illness 
Other  Symptoms 


Mode  of  Contagion 


Period  of  Contagion 


Period  of  Incubation 
Mode  of  Onset 

Time  of  Eruption 

Character  of  Eruption 

Disappearance  of  Eruption 
Duration  of  Illness 
Other  Symptoms 
Mode  of  Contagion 

Period  of  Contagion 


Tetanus  bacillus  always  enters  through  an 
external  wound.  Puerperal  tetanus  caused  by 
infected  water. 

Typhoid  Fever 

From  eight  to  fourteen  days;  sometimes 
twenty-three  days. 

Gradual  onset.  Symptoms  of  general  malaise, 
gradual  rise  of  temperature,  headache,  epis- 
taxis. 

Seventh  to  tenth  day. 

Small,  red  spots,  somewhat  raised;    disappear 
completely  under  pressure,  found  more  fre- 
quently on  upper  abdomen,  also  on  chest  and 
back,  occur  in  repeated  crops. 
No  definite  time  or  manner. 
From  four  to  six  weeks. 

Regular  daily  remissions  of  temperature,  tym- 
panites, intestinal  hemorrhage  and  perforation, 
nervous  symptoms. 

By  way  of  the  gastro-intestinal  canal,  in  food 
and  water.  Directly  from  stool  or  urine  of 
patient.     Flies. 

During  entire  illness.  Also  waterways  may  be 
contaminated  by  stools  for  a  long  time  and 
some  persons  are  "  typhoid  carriers." 

Typhus  Fever 

About  nine  days. 

Yery  suddenly  with  chill,  rapid  rise  in  tem- 
perature, extreme  prostration. 
Third  to  seventh  day;  average,  fourth  or  fifth 
day. 

Red  macules  size  of  pinhead,  beginning  on 
shoulders  and  flanks  and  flexor  surfaces,  fore- 
arms, become  hemorrhagic  in  a  few  days;  dark 
red  subcuticular  mottling  of  skin  follows. 
Begins  to  fade  in  five  to  seven  days;  petechial 
eruption  persists  into  convalescence. 
Crisis  comes  about  end  of  second  week,  after 
which  convalescence  is  rapid. 
Continuous  high  temperature  (104-106),  pro- 
found nervous  disturbances  and    prostration. 
From  patient  directly,  infected  bedding,  and 
clothing  highly  dangerous,  germ  not  yet  iso- 
lated. 
During  entire  iUness. 


INFECTIOUS  DISEASES 


303 


Period  of  Incubation 
Mode  of  Onset 

Eruption 

Duration  of  Illness 
Other  Symptoms 


Period  of  Contagion 


Whooping  Cough 
Seven  to  twenty-one  days. 
Symptoms  bronchial  cold,  one  week,  then  con- 
vulsions, cough. 
None. 

Six  to  twelve  weeks. 

Paroxysmal  cough  followed  by  "  whoop." 
Bronchial  complications.  Sometimes  resem- 
bles pneumonia  in  some  features.  Sometimes 
nervous  and  eye  symptoms. 
From  the  very  earliest  symptoms  until  the  end 
of  the  disease. 


Period  of  Incubation 
Mode  of  Onset 

Time  of  Eruption 

Character  of  Eruption 


Disappearance  of  Eruption 
Duration  of  Illness 

Other  Symptoms 


Yellow  Fever 
From  one  to  seven  days. 
General  muscular  pains,  sudden  chill,  head- 
ache, facial  congestion,  temperature  103  to  105. 
No  regular  eruption;   jaundice  fourth  to  sev- 
enth day. 

Occasionally  erj'thema,  urticaria,  or  even  pus- 
tules.    Usually   petachial  to  jaundiced   skin. 
Most  marked  in  third  stage. 
After  seventh  day. 

Varies  greatly.  The  average  is  four  days  to 
one  week  in  cases  that  recover. 
Has  three  stages.  There  is  persistent  vomit- 
ing, finally  becoming  "  black  vomit  "  from 
mucous  membrane  hemorrhages.  Jaundice 
is  apt  to  be  marked  and  the  third  stage  is 
marked  by  kidney  and  liver  complications 
often  ending  in  serious  mixed  infections  of  a 
secondary  character. 

Infection  carried  by  the  mosquito,  stegomyia 
fasciata.  Infection  also  directly  from  blood 
of  patient  during  first  four  days  of  disease. 
No  infection  carried  by  fomites. 

Methods  in  use  by  physicians  to  protect  themselves,  their  families,  their 
patients,  and  the  public. —  This  heading  involves  so  much  said  in  other  portions 
of  this  book  that  we  will  here  make  reference  to  the  portions  involved  and 
present  brief  data  from  the  literature  of  several  of  the  state  boards  of  health. 
A  study  of  any  recent  work  upon  practice  of  medicine  answers  any  question 
arising,  and  it  is  not  necessary  to  give  such  data  here  except  such  as  relate 
specifically  to  public  health  and  state  medicine. 

Quarantine  is  considered  in  a  separate  chapter  to  which  we  refer  while 
sidelights  are  thrown  upon  the  subject  in  Chapters  I,  II,  III,  IV,  IX,  XI,  XVI 
XVII,  and  XIX. 


Mode  of  Contagion 


304  HYGIENE 

Disinfection  is  fully  treated,  for  our  present  purpose,  in  the  special  chap- 
ter upon  the  subject. 

Actinomycosis  is  discussed  in  the  Appendix,  under  the  heading,  "  Dis- 
eases of  animals  communicable  to  man." 

Anthrax  is  found  in  the  same  paper. 

Bubonic  Plague  is  considered  in  Chapter  VII  and  in  Chapter  IX  under 
California.     For  other  references  see  the  general  index. 

Cerebrospinal  Meningitis. —  The  especial  precautions  are  to  destroy 
sputum  and  all  secretions  from  the  nose  and  mouth.  Especial  care  should  be 
exercised  to  wash  the  hands  in  an  antiseptic  solution  before  leaving  the  house. 
The  writer  has  been  in  contact  with  the  epidemic  form  of  this  disease,  and 
cannot  be  too  positive  upon  the  necessity  of  isolation  and  disinfection  in  this 
form  of  the  affection. 

Chickenpox. —  This  disease  is  frequently  reported  when  the  real  trouble 
is  smallpox.  Adults  seldom  have  chickenpox  and  a  pustular  eruption  in  a 
person  over  twelve  years  of  age  looks  suspicious,  especially  if  papular  and 
becoming  vesicular.  Children  with  chickenpox  must  be  kept  from  school  and 
infected  clothing  must  be  destroyed  or  disinfected  as  in  more  severe  diseases. 

Cholera  is  seldom  encountered  in  this  country,  and  in  case  of  epidemic 
it  is  weU  to  follow  all  advice  given  by  the  health  boards.  Cholera  Infantum 
or  acute  milk  infection  and  Cholera  Morbus  are  well  considered  in  the  follow- 
ing, from  the  Indiana  State  Board  of  Health: 

PRECAUTIONS  AGAINST  CHOLERA  MORBUS,  SUMMER  DIARRHOEA, 

AND  DYSENTERY 

All  of  these  well-known  diseases  occur  principally  during  the  summer  and  autumn. 

Cholera  morbus  is  caused  by  improper  food  and  sudden  chilling  of  the  body  after 
exposure  to  great  heat.  Certain  substances  will  produce  it  in  certain  persons,  such,  for 
instance,  as  veal  or  shell  fish,  and  all  dishes  cooked  with  milk,  such  as  rice  pudding, 
cream  puffs,  and  even  ice  cream,  when  they  are  kept  too  long.  Ripe  and  overripe 
fruit,  especially  if  taken  with  large  draughts  of  ice  water,  will  also  cause  it;  but  sound, 
ripe  fruit  is  a  natural  food  in  hot  weather,  and  wholesome.  Avoid  becoming  chilled 
during  sleep.  In  a  climate  as  changeable  as  ours,  a  light  blanket  should  always  be 
at  hand,  to  be  drawn  up  in  case  it  suddenly  becomes  cold  during  the  night.  Persistent 
summer  diarrhoea  is  sometimes  caused  by  malaria  or  impure  water.  The  conditions 
liable  to  contaminate  air  and  water  should  be  carefully  sought  out  and  remedied. 
Water  can  be  rendered  safe  by  boiling. 

As  dysentery  is  often  epidemic,  it  is  wise  to  consider  every  case  as  a  possible  source 
of  danger  to  others,  and  to  disinfect  the  discharges  with  the  greatest  care. 

HOW  TO  REAR  A  HEALTHY  BABY 

Leaflet  issued  by  the   Wakefield  (Eng.)  Sanitary  Aid  Society 

Food.  If  the  mother's  milk  is  good  and  plentiful,  the  child  should  have  no  other 
food  whatever  until  seven  months  old.  If  the  mother  has  not  enough  milk,  cow's  milk 
should  be  given  in  addition  to  it,  but  not  in  place  of  it;  the  two  milks  will  not  disagree. 
While  suckling,  the  mother  should  take  plain  and  wholesome  food;  stimulants  are  not 
necessary,  and  spirits  are  distinctly  harmful. 


INFECTIOUS  DISEASES  305 

Times  of  feeding. —  For  the  first  month  the  baby  should  be  fed  regularly  every  two 
hours  by  day  and  every  four  hours  by  night.  In  the  second  month,  feed  every  two  and 
a  half  hours  by  day;  in  the  third  month,  every  three  hours  by  day  and  twice  during  the 
night.  Gradually  increase  the  interval  between  the  feeds,  so  that  at  seven  months 
old  the  child  is  fed  once  every  four  hours  by  day  and  once  in  the  night,  if  awake. 

On  no  account  must  a  baby  be  put  to  the  breast  every  time  it  cries;  it  may  be 
crying  for  some  other  reason  than  hunger.  Look  at  the  clock,  and  //  it  is  not  feeding 
time,  do  not  feed  it;  a  teaspoonful  or  two  of  clean  cold  water  will  often  comfort  it. 
Fretfulness,  stomach  ache,  and  sickness  are  caused  if  an  infant  is  fed  irregularly  or 
too  frequently. 

Bottle  feeding. —  If  there  is  not  enough  mother's  milk,  the  diet  must  be  supple- 
mented by  fresh  unskimmed  cow's  milk.  A  bottle  prepared  as  follows  should  then 
take  the  place  of  one  or  more  feeds  at  the  breast. 

All  milk  used  for  children  should  be  well  scalded  by  placing  in  a  clean  jar  and 
keeping  on  the  fire  in  a  saucepan  of  boiling  water  for  twenty  minutes.  Do  this  as  soon  as 
the  milk  comes  to  the  house.     Then  put  the  jar  in  a  cool  place,  and  keep  it  covered. 

The  following  are  the  proper  amounts  for  each  feed: 

For  an  infant  a  week  old  use  one  tablespoonful  of  this  milk,  two  tablespoonfuls 
of  water  or  barley  water,  and  a  small  lump  of  sugar. 

Gradually  increase  the  quantities  so  that  by  the  fourth  week  each  feed  consists 
of  two  tablespoonfuls  of  milk  to  three  and  a  half  of  water,  with  a  lump  of  sugar. 
By  the  third  month  use  three  teaspoonfuls  of  milk  and  three  of  water.  From  three  to 
six  months  old  the  child  should  have  eight  to  twelve  tablespoonfuls  in  each  bottle, 
of  which  not  more  than  two  or  three  are  water.  From  eight  months  onward  the  child 
should  be  able  to  digest  pure  milk,  scalded  and  sweetened,  and  should  have  one  and 
a  half  pints  a  day. 

If  the  infant  is  having  no  mother's  milk,  the  cow's  milk  should  be  enriched,  if 
possible,  by  adding  a  teaspoonful  of  fresh  dairy  cream  to  the  milk  for  each  bottle  before 
scalding.  Do  not  use  the  cream  sold  in  jars,  as  it  may  have  chemicals  added  to  make 
it  keep,  which  would  be  hurtful  to  a  baby. 

When  the  right  quantity  of  milk,  water,  cream,  and  sugar  has  been  mixed,  the 
food  should  be  warmed  and  placed  in  a  perfectly  clean  bottle.  Use  an  old-fashioned 
"  boat  bottle  "  with  a  teat  that  can  be  turned  inside  out  for  cleaning.  Tube  bottles 
are  dangerous.  Directly  after  each  feed  cleanse  the  bottle  and  teat  thoroughly,  and 
place  them  in  clean,  cold  water  until  wanted  again. 

If  a  child  does  not  take  all  the  food,  what  is  left  should  not  be  kept.  Never  give 
milk  that  is  not  quite  fresh  to  any  child. 

Weaning. —  As  a  rule  a  child  should  be  gradually  weaned  at  the  eighth  month. 
Suckling  beyond  this  time  is  most  injurious  to  mother  and  child,  and  it  is  untrue  that 
the  mother  will  not  become  pregnant  while  she  is  suckling.  Take  care  that  the  baby 
has  plenty  of  cow's  milk  after  weaning;  a  healthy  weaned  child  of  nine  months  old 
needs  at  least  one  and  a  half  pints  of  good  scalded  milk  a  day. 

By  the  time  the  child  has  four  teeth  it  may  have  its  milk  thickened  with  baked 
flour,  rusks,  toasted  bread,  or  the  prepared  infant's  foods.  On  no  account  give  any 
sort  of  bread  food  before  the  teeth  are  through,  as  the  infant  cannot  digest  it,  and 
convulsions  may  be  caused.  Watch  over  the  child's  feeding  carefully.  Do  not  give 
it  "  just  what  we  have  ourselves."     Do  not  let  the  other  children  give  it  "  little  bits." 

When  a  child  is  ten  months  old  it  may  have  milk  pudding,  bread,  and  milk,  por- 
ridge, egg,  or  a  little  broth,  but  still  give  it  plenty  of  milk.  Train  it  to  regular  meal 
times,  and  to  eat  and  drink  slowly. 


306  HYGIENE 

Never  give  the  baby  tea  or  coffee.  Children  would  be  much  sturdier  if  given  warm 
milk  instead  of  tea  or  coffee  till  four  years  old. 

The  following  things  are  also  harmful  for  little  children:  Beer,  spirits,  wine,  new 
bread,  currants,  unripe  fruit,  pickles,  salads,  soothing  syrups,  or  teething  powders. 
The  use  of  the  two  last  undermine  the  health  of  many  children.  No  medicine  should 
be  given  except  by  doctor's  advice. 

A  baby's  clothing  should  be  clean  and  warm,  but  not  tight  about  the  body. 

A  baby  should  be  washed  all  over  every  day  with  warm  water  and  soap.  Also,  night 
and  morning,  fix  a  piece  of  clean  rag  firmly  round  the  finger,  dip  into  clean  water,  and 
thoroughly  wash  the  gums  and  roof  of  thechild's  mouth.  Burn  the  rag.  You  are  strongly 
advised  not  to  use  a  comforter*     It  is  often  the  cause  oi  thrush  and  other  troubles. 

A  baby  should  be  taken  out  whenever  possible  if  the  weather  is  fine.  Babies 
need  pure  fresh  air  —  indoors  and  outdoors — -even  more  than  grown  people;  those 
who  have  the  most  of  it  will  be  the  least  liable  to  bronchitis  and  will  sleep  the  best. 
An  infant  should  have  a  separate  cot,  and  not  stay  in  the  mother's  bed  during  the  night. 

A  healthy  baby  should  gain  four  to  six  ounces  in  weight  every  week.  If  it  suffers 
from  diarrhoea  or  indigestion,  in  spite  of  every  care,  take  it  to  a  doctor  without  delay. 

The  care  of  infant  life  is  a  subject  of  vast  economic  importance  and 
justifies  a  separate  chapter  in  this  book.  Maternities  are  considered  in 
Chapter  V,  but  lack  of  space  precludes  a  general  consideration  of  infant  feed- 
ing and  hygiene.  The  editor  is  led  to  this  decision,  because  nearly  all  recent 
works  upon  children's  diseases  discuss  the  matter  more  fully  than  is  possible 
here.  Furthermore,  boards  of  health  everywhere  are  issuing  pamphlets  upon 
the  subject.     Milk  is  considered  in  Chapter  VIII. 

Diarrhoea  and  Dysentery  are  usually  caused  by  impure  water  or  milk, 
and  precautions  similar  to  those  for  typhoid  are  advised,  but  need  not  be  so 
stringent.  Epidemic  dysentery  must  be  watched  with  the  utmost  of  care. 
Boiling  the  water  and  disinfecting  the  discharges  are  necessary  in  this  whole 
class  of  affections. 

Diphtheria. —  In  the  chapter  upon  epidemics  reference  is  made  to  this 
disease  and  shght  discussion  is  found  in  several  other  sections  of  this  book. 
See  the  general  index.  Especial  care  is  necessary  to  act  promptly  in  immun- 
izing with  antitoxin.  See  the  chapter  upon  immunity.  Practically  every 
state  has  issued  special  bulletins  upon  this  disease,  but  the  "  Special  Diph- 
theria Number,  Bulletin  of  the  State  Board  of  Health  of  Maine,"  is  especially 
good.  It  is  a  disease  so  familiar  to  the  general  practitioner  that  a  full  dis- 
cussion is  not  necessary  here. 

Erysipelas  requires  that  all  persons  about  the  patient  be  very  careful  of 
the  secretions  and  the  hnen  soiled  by  the  patient  or  the  dressings  removed 
from  him.     Clothing  and  bed  linen  should  be  disinfected  very  carefuUy. 

German  measles  demands  the  same  precautions  as  does  measles,  only  this 
is  usually  a  milder  disease. 

Glanders. —  See  diseases  of  animals  in  the  Appendix. 

Gonorrhcea. —  See  what  Dr.  Miller  writes  in  Chapter  VI. 

Hydrophobia. —  See  the  chapter  upon  Immunity. 

*A  comforter  is  a  rubber  nipple  or  other  article  for  the  baby  to  keep  in  its  mouth- 
Keep  everything  out  of  the  baby's  mouth  except  pure  food  and  pure  water. 


INFECTIOUS  DISEASES  307 

Leprosy. —  This  disease  is  seldom  seen  by  our  American  practitioners. 
Cases  should  be  segregated,  in  the  opinion  of  most  authorities. 

Malarial  fevers. —  See  the  chapter  upon  epidemics  and  the  several  places 
where  mosquitoes  are  discussed,  as  per  index. 

Measles. —  Among  other  things,  the  special  bulletin  upon  this  disease 
issued  by  the  Maryland  Board  says: 

Often,  when  the  rash  of  measles  disappears,  the  skin  peels  off  in  small  flakes  or 
scales.  It  is  not  positively  known  that  this  shed  skin  is  infectious,  but  it  is  suspected. 
Therefore  when  removing  clothing  from  the  patient's  body,  keep  the  inside  inward, 
and  roll  the  clothing  up  so  as  to  prevent  the  scales  from  being  scattered  about.  Simi- 
larly in  changing  bed  linen;  don't  pull  it  off  the  bed.  Roll  it  up,  body  side  inward. 
These  things  may  be  wadded  up  tightly  and  put  into  a  clean  pillow  slip,  or  else  rolled 
into  paper  parcels,  after  which  they  may  be  carried  safely  down  stairs  and  put  directly 
into  a  wash  boiler  and  boiled.  Paper  bags  are  convenient  and  safe  receptacles  for 
such  infected  articles  as  you  have  to  carry  to  the  kitchen  fire.  The  bags  are  cheap 
enough  to  burn. 

The  things  used  by  the  patient  in  taking  food  or  medicine  should  always  be 
disinfected  before  being  taken  out  of  the  room,  and  before  being  used  again.  At- 
tendants must  wash  the  hands  whenever  leaving  the  bedside  and  should  never  leave 
the  room  without  washing  the  hands,  and  if  possible  the  outer  dress  should  be  changed. 
In  moving  about  the  house  care  should  be  taken  not  to  loiter  about  or  come  into 
contact  with  other  persons  any  more  than  can  be  avoided.  Remember  that  the  in- 
fectious material  practically  all  comes  out  of  the  patient's  mouth  and  nose,  so  that  if 
you  keep  your  hands  and  clothing  free  from  these  discharges  you  will  be  pretty  safe. 
When  Can  the  Patient  Come  Back  into  the  Family  Circle  ? 

When  the  doctor  says  that  recovery  is  complete,  after  the  body  has  been  bathed, 
and  clean  clothing  put  on.  If  cough  still  persists,  the  same  care  should  be  kept  up, 
since  the  patient  may  spread  the  disease  through  coughing.  A  patient  recovering 
from  measles  will  have  delicate  lungs  for  a  rather  long  time,  and  must  not  associate 
with  or  be  fondled  by  another  person  who  may  have  lung  trouble.  Few  diseases  pro- 
vide a  more  favorable  chance  for  consumption  to  develop  than  does  measles. 
%■'  After  measles  the  eyes  are  sometimes  weak  for  a  considerable  time,  and  children 
of  school-going  age  should  not  be  taxed  heavily  with  lessons,  particularly  at  night. 
Altogether  measles  lays  a  good  foundation  for  later  ill  health,  and  a  child  should  be 
watched  carefully  for  some  time  after  his  attack  is  apparently  over. 

Mumps. —  Children  should  not  be  admitted  to  school  until  at  least  one 
week  after  the  disappearance  of  all  symptoms. 

Ophthalmia  neonatorum. —  The  Nebraska  Board  directs  as  follows: 
Rule  29.  The  disease  ophthalmia  neonatorum,  prevalent  only  among  newborn 
infants,  is  one  of  the  most  fruitful  sources  of  blindness.  All  things  considered,  where 
there  is  the  least  suspicion  of  the  prevalence  of  any  gonorrhoeal  infection,  or  a  muco- 
purulent discharge  from  the  vagina  during  birth,  the  attending  physician  shall  take 
precautionary  measures  at  once  to  prevent  this  fearful  disease.  This  consists  in  the 
instillation  of  two  drops  of  a  two  per  cent  solution  of  nitrate  of  silver  in  the  eyes  of  the 
newborn  child,  after  thoroughly  cleansing  the  eyelids,  then  parting  them  and  intro- 
ducing the  drug.  When  there  is  reason  to  suspect  gonorrhoeal  contagion,  this  must  be 
repeated  the  second  day.  While  the  instillation  of  the  silver  solution  may  cause 
hyperaemia  it  disappears  in  a  few  days,  and  the  enormous  value  of  this  treatment  far 
outweighs  the  few  accidents  which  have  occurred  after  its  use.  It  is  the  duty  of  phy- 
sicians, nurses,  and  directors  of  public  charities  to  disseminate  among  the  poorer 


308  HYGIENE 

classes  a  knowledge  of  the  dangers  of  this  disease  and  the  necessity  of  prompt  treat- 
ment. Disinfection  of  the  clothing  of  the  patient,  and  burning  of  all  cloths,  etc.,  is 
essential,  as  there  is  great  danger  of  contamination. 

Pediculosis. —  Directions  are  given  in  Chapter  III. 

Pneumonia. —  Only  a  small  class  of  cases  is  definitely  proven  to  be  con- 
tagious, although  many  authorities  claim  that  all  cases  are  liable  to  be  more 
or  less  dangerous. 

Puerperal  fever. —  The  Nebraska  Board  says: 

Puerperal  fever  is  a  fearfully  fatal  disease.  Hence  every  attendant  upon  cases 
of  labor  should  by  the  use  of  antiseptic  measures  sedulously  guard  against  the  occur- 
rence of  the  disease.  The  hands,  and  all  instruments  and  appliances,  should  be  care- 
fully disinfected,  and  all  discharges  subject  to  decomposition  should  be  promptly  re- 
moved and  buried  or  destroyed.  The  only  way  to  avoid  this  terrible  disease  is  for 
every  practitioner  to  recognize  his  personal  responsibility  in  the  care  of  his  patient, 
and  he  who  does  not  is  guilty  of  criminal  negligence. 

Relapsing  fever. —  Similar  to  most  infections  of  its  character. 

Ring  worm. —  Exclude  children  from  school  until  cured. 

Scabies. —  Same  as  ring  vi^orm.     Better  burn  clothing. 

Scarlet  fever. —  The  Connecticut  Board  issues  a  splendid  bulletin  upon 
this  disease  and  among  other  things,  directs: 

Precautionary  Directions 

The  room. —  When  a  person  is  attacked  with  scarlet  fever,  place  him  in  a  room 
by  himself,  the  larger  the  better,  and  by  preference  in  the  top  of  the  house.  Before 
his  admission  remove  all  unnecessary  articles  from  the  room.  Carpets,  woolen 
curtains,  and  upholstered  furniture  are  especially  liable  to  become  infected. 

The  nursing. —  Not  more  than  one  or  two  attendants  should  occupy  the  room  to 
nurse  the  sick  person.  The  nurse  should  wear  no  clothing  which  would  be  injured 
by  washing.     Children  especially  should  not  be  allowed  to  enter  the  room. 

The  contagion  is  contained  in  all  the  excretions  of  the  patient,  and  in  the  bran-like 
scales  of  the  outer  skin  that  are  shed  so  freely  in  convalescence.  The  matters  that 
come  from  the  head,  throat,  nose,  and  skin  are  especially  contagious. 

It  is  an  important  point  to  deal  with  the  contagion  at  its  source  and  act  promptly, 
under  all  circumstances.  Delay  gives  opportunity  for  its  diffusion.  House  flies  and 
other  insects,  by  access  to  the  vessels  containing  excreta,  may  carry  it  about.  Cats 
and  dogs  should  be  rigidly  excluded.  Drying  may  convert  it  into  dust  to  float  in  the 
air.     Destroy  the  infection  at  the  point  of  origin,  if  possible.     It  is  possible. 

The  excreta  should  be  received  in  vessels  containing  a  quart  of  Solution  No.  1 
for  each  discharge,  and  should  be  left  in  the  vessel  at  least  an  hour  before  throwing 
into  privy  vault  or  water  closet.  The  vomited  matters  and  sputum  should  be  received 
in  vessels  containing  the  like  solution. 

Or  milk  of  lime,  Solution  No.  4,  may  be  used  and  mixed  intimately  with  the  ex- 
creta until  it  is  strongly  alkaline  (tested  by  litmus  paper). 

All  linen  and  cotton  articles  used  about  the  patient  should  be  at  once  immersed 
in  a  wooden  tub  containing  two  fluid  ounces  of  Solution  No.  3  to  each  gallon  of  water, 
and  left  in  soak  not  less  than  two  hours,  or  in  a  solution  of  carbolic  acid,  §  iii  to  a 
gallon,  for  four  hours.  They  should  then  be  sent  to  the  laundry  and  boiled.  Under 
no  circumstances  should  the  sheets  or  underclothing  he  carried  from  the  room  dry, 
and  care  should  be  taken  not  to  shake  off  the  brannv  scales  to  infect  other  articles. 


INFECTIOUS  DISEASES  309 

N.  B. —  Solutions  No.  2  and  3  should  not  be  placed  in  metal  receptacles.     Only 
a  wooden  tub  or  earthen  crock  is  suitable  for  these  solutions. 
Solution  1  is  bichloride. —  See  "  Disinfection." 
Solution  2  is  bichloride  and  perm.  pot. 
Solution  3  is  bichloride,  weak. 
Solution  4  is  milk  of  lime. 

Outer  garments  of  wool  or  silk,  and  similar  articles  which  would  be  injured  by 
immersing  in  a  disinfecting  solution  or  by  boiling,  should  be  exposed  for  two  hours 
to  dry  heat  230  degrees  F.,  or  fumigated  with  burning  sulphur  or  formaldehyde  gas. 
Any  articles  of  clothing  or  bedding  taken  from  the  room  before  disinfecting  should 
be  tied  up  in  a  sheet  saturated  with  Solution  No.  3. 

Dust  and  dirt  must  be  removed  by  damp  cloths,  as  sweeping  and  dusting 
are  prohibited.     These  cloths  should  be  at  once  thrown  into  the  solution  or  into  the  fire. 

Books,  toys,  and  articles  used  to  amuse  the  patient  when  convalescent  are  best 
disposed  of  by  burning  them  in  the  room.  Under  no  circumstances  should  toys  be 
borrowed  to  return  nor  used  by  the  well. 

Physicians,  nurses,  and  others  who  come  in  contact  with  the  disease  may  convey 
the  poison  to  persons  at  a  distance. 

No  children  should  be  allowed  to  go  to  school  from  the  house,  nor  allowed  to  play 
with  others  that  have  not  had  the  disease.  As  a  rule  the  cases  where  the  child  is  not 
confined  to  bed  oftenest  spread  infection,  as  little  care  is  excised  for  prevention. 

When  fully  convalescent  the  patient  should  receive  a  warm  bath  in  carbolized 
water,  or  carbolic  soap  may  be  used.  When  peeling  has  entirely  ceased  and  no  rough- 
ness of  skin  remains  there  is  little  if  any  danger  to  be  apprehended  of  conveying  the 
disease.  It  is  difficult  to  fix  any  definite  period  when  there  is  no  longer  any  danger  of 
conveying  the  disease,  as  the  types  and  varieties  are  so  numerous,  and  of  all  grades  of 
severity.  From  a  wide  experience  of  treating  the  disease,  the  average  period  of  six 
weeks  has  been  stated;  the  more  cautious  give  eight  weeks  as  the  proper  period  before 
a  child  should  attend  school  and  mingle  freely  with  others.  As  the  sequels  of  scarlet 
fever  are  so  severe,  this  period  is  not  oppressive,  and  in  fact  is  demanded  by  the  best 
interests  of  the  public. 

All  persons  recovering  from  scarlet  fever  should  be  considered  dangerous,  and 
therefore  should  not  attend  school,  church,  or  any  public  assembly,  or  use  any  public 
conveyance,  so  long  as  the  skin  is  peeling  off,  or  the  eyes  are  sore  or  symptoms  of 
dropsy  exist. 

Inunction  during  the  "  peeling  process  "  is  useful  in  preventing  infection.  The 
body,  head,  and  limbs  should  be  thoroughly  anointed  with  vaseline,  camphorated  oil, 
or  similar  substance,  as  the  attending  physician  may  direct,  should  he  think  it  proper 
to  use  them. 

And  the  entire  surface  of  the  body  should  receive  occasional  ablutions  with  solu- 
tions of  chlorinated  soda  (Labaracque's  solution)  diluted  with  one  part  to  twenty  of 
water. 

The  dishes  used  in  the  sick  room  should  be  washed  separately,  first  in  Solution 
No.  1,  then  in  hot  water.  For  many  purposes  linen  or  cotton  rags  are  useful  instead 
of  handkerchiefs,  etc.,  especially  when  the  throat  symptoms  are  present.  After  use 
they  should  be  at  once  burned,  together  with  all  fragments  and  refuse. 

Perfect  cleanliness  should  be  enjoined,  especially  if  the  attendant  is  obliged  to 
mingle  with  other  people.  As  the  hands  are  very  liable  to  be  infected  from  the  neces- 
sary care  of  the  patient,  a  disinfecting  solution  (chlorinated  soda,  one  part  to  ten  of 
water)  should  be  used.     After  the  use  of  the  disinfecting  solution  the  hands  should  be 


310  HYGIENE 

washed  with  plain  soap  and  water.     The  disinfectant  solution  should  be  also  provided 
for  the  physician's  use  on  leaving  the  room. 

The  above  precautions  and  isolation  are  always  necessary  in  the  mild  as  well  as 
the  severe  forms  to  prevent  the  spread  of  the  disease. 

In  the  sickroom  free  ventilation  and  cleanliness  are  essential  aids  to  disinfection. 

In  case  of  death  the  body  should  be  wrapped  in  a  sheet  saturated  with  sixty  grains 
of  corrosive  sublimate  and  two  tablespoonfuls  of  common  salt  in  a  gallon  of  hot  water; 
or  six  ounces  of  pure  carbolic  acid  in  a  gallon  of  hot  water;  and  if  to  be  carried  out  of 
town  must  also  be  enclosed  in  an  air-tight  coffin,  hermetically  sealed. 

Funerals  of  those  dead  from  scarlet  fever  should  always  be  strictly  private.  The 
bodies  should  never  be  exposed  to  view. 

Smallpox. —  See  the  chapters  upon  Epidemics  and  Immunity. 

Syphilis. —  See  Chapter  VL 

Tetanus. —  The  Michigan  Board  says: 

The  tetanus  germ  exists  and  thrives  in  the  incrustation  or  dust  of  filth;  and  a 
wound  from  a  rusty  nail,  or  from  a  powder  explosion,  as  from  fireworks,  etc.,  permits 
this  dust  so  laden  with  tetanus  germs  to  enter  the  abrasion  of  the  skin,  and,  sealed 
in  this  excellent  medium,  the  tetanus  germ  becomes  prolific,  causing  the  death  of  the 
human  being  within  a  short  time.  Prompt  medical  treatment  and  the  administration 
of  prophylactics  are  absolutely  necessary  for  the  saving  of  life.  A  pamphlet  bearing 
on  the  especial  relation  of  tetanus  to  Fourth  of  July  celebration  with  improper  fire- 
works has  been  issued  by  the  state  department  of  health,  and  copies  of  the  same  will 
be  mailed  free  upon  request. 

Also  see  chapter  upon  Immunity. 

Trachoma. —  See  section  upon  inspection  of  immigrants  (index),  and 
works  upon  eye  diseases. 

Trichiniasis. —  See  Appendix  and  section  upon  meats  in  Chapter  VIII. 

Tuberculosis. —  See  Chapter  XIX  and  index  for  other  references. 

Typhoid  fever. —  See  Chapter  XII  and  index  for  other  references. 

Typhus  fever. —  Same  as  typhoid. 

Whooping  cough. —  Exclude  child  from  school  or  other  public  places 
and  maintain  a  mild  or  modified  quarantine. 

Yellow  fever. —  Referred  to  in  several  places.     See  general  index. 

Note. —  Every  physidian  should  secure  copies  of  the  regulations  of  his 
own  state,  county,  or  city,  and  be  governed  by  them. 


V"^,*-^- 


X 


